UNION COUNTY TAX ADMINISTRATOR 
                                                   EMPLOYER'S RETRUN OF LICENSE FEE WITHHELD 
                                                   If no wages were paid this period mark "NONE" and return this form

1. Salaries, wages, commission & other compensation paid all  
    employees for services in This County                                7. Overpayment to be credited o next quarter
2. Tax Due at -               0.50%                                      I hereby certify that the information, schedules, statements and exhibits 
3. Adjustment for preceding quarters (past due balances /                filed herewith are true and correct.
    underpayments
4. Penalty 5.00% per mnth and portion of max 25% min $25                 Signed
5. Interest 12.00% per annum
6. BALANCE DUE                                                           Official Title                               Date

                                                              Account No.
                                                                         FOR QUARTER ENDING
Name:                                                                                                                 Make checks payable and mail to  
                                                                                                                      Union County Tax Administrator 
                                                                                                                      P.O. Box 60 
Address:                                                                 RETURN DUE ON OR BEFORE                      Moganfield, KY 42437

City                                      State AL            Zip                                                    Phone:               (270) 389-3438 
                                                                         FED ID NO. / SSN                            Fax:                     (270) 389-4232 
                                                                                                                      
Phone Number

                                                   *PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS