EMPLOYEE CERTIFICATION OF RESIDENCY                            OR NON RESIDENCY 
                        WARREN COUNTY SCHOOLS OCCUPATIONAL TAX OFFICE             
                        P.O. Box 51530, 303 Lovers Lane, Bowling Green, KY 42103 
                                                 
♦ The information on this form will determine if Warren County Schools Occupational Tax is to be 
  withheld from your wages.  
 
♦ If you are unsure of the school district you reside in, please call our office for verification at 
  (270) 842-7168.  
 
♦ If you change your place of residence during the year, it is very important that you to notify your 
  payroll department. 
 
FULL NAME:  _______________________________________________________________ 
 
SOCIAL SECURITY NUMBER:  ________________________________________________ 
 
HOME ADDRESS:  ___________________________________________________________ 
(or temporary address)  
     _________________________________________________ 

______ I DO live in the Warren County School District. 
 
______ I DO NOT live in the Warren County School District. 
 
SIGNATURE:  _______________________________________________  DATE:  ______________________ 
 
 This form is to be filled out by you and retained by your employer.  It becomes your employer’s 
  authorization to withhold the Warren County Schools Occupational Tax from your wages.   
 
Questions may be directed to: 
 
                                                FINANCE DIRECTOR 
                                               P.O. BOX 51530
                                         BOWLING GREEN, KY 42102-5830 
                                                PHONE: (270) 842-7168    FAX: (270) 842-3411