Phone No. (270) 842-7168     WARREN COUNTY SCHOOLS OCCUPATIONAL TAX                                                 Fax No. (270) 842-3411
                                  303 Lovers Lane, Bowling Green, KY 42103

                                  EMPLOYERS' ANNUAL RECONCILIATION OF
                                           LICENSE FEE/TAX WITHHELD
                                                          Social Security # or 
Account #:    _________________________________           Federal ID #:         ________________________

Print Name & Address of Employer:                                                                                   For Year Ended
                                                                                                                   Month Day Year

Phone #: _______________________           Email Address: ___________________________________________

                                        WITHHOLDING PAYMENT SCHEDULE

Jan                               April                     July                                            Oct

Feb                               May                       Aug                                             Nov
March or                          June or                   Sept or                                         Dec or 
1st Qtr                           2nd Qtr                   3rd Qtr                                         4th Qtr

                     Number of Employees:                                              Total Payments              $

                                                            FEE COMPUTATION
*****IMPORTANT****
                             1.) Total Wages, Tips, Other Compensation per Box 1 of Federal Form W-
    APPROPRIATE                   2 or W-3
SCHEDULES MUST               2.) Add: Deferred Compensation Contributed by Employees (i.e., 
    BE ATTACHED                   retirement, profit sharing, deferred compensation plans, cafeteria plans, 
                                  etc.)
    Enclose Copies of 
Federal Forms W-2 and        3.) Add: Welfare Benefit, Fringe Benefit, or Other Benefit Plan Payments 
W-3, Transmittal of               Contributed by an Employee
    Wage and Tax             4.) Total Gross Compensation (Add Lines 1 through Line 3)
    Statements, or a 
Detailed Employee            5.) Less: Total Gross Compensation Paid for Service Outside of Warren 
    Listing with the              County, Kentucky and/or Gross Nonresident Compensation
Required Equivalent 
                             6.) Taxable Compensation (Subtract Line 5 from Line 4)
        Information

                             7.) Occupational License Fee (Line 6 X .005)
         DUE
    FEBRUARY 28
                             8.) Total Payments Remitted
        Remit To:
                             9.) Balance Due (If Line 7 Exceeds Line 8 = Line 7 Minus Line 8)
    Warren County 
Schools Quarterly Tax 
                             10.) Penalty @ 5% per month (not to exceed 25%; Minimum $25)
         Return
P.O. Box 890947
    Charlotte, NC            11.) Interest @ 1% per month from Due Date
    28289-0947
                             12.) TOTAL AMOUNT DUE        (Line 9 Plus Lines 10 and 11)
         Website:

www.warren.kyschools.us      13.) Overpayment Claimed (If Line 8 exceeds Line 7)
Occupational Tax Office Link                 Refund           Credit to next year estimated payment
RETURN MUST BE SIGNED - I hereby certify, under penalty of perjury, that the statements made herein and in any supporting schedules are true, correct, and complete to the 
best of my knowledge.

    SIGNATURE TITLE                                                                                                DATE