paid all employees for services In This County
1. Salaries, wages, commissions & other compensation                   $                    7. Overpayment to be credited to next quarter $
2. TaxDueat-              1.00%                                        $
3. Adjustment for preceding quarters (past due balances 1                                      I hereby certify that the information, schedules, statements and exhibits filed
   underpayments)                                                      $                       herewith are true and correct.
4. Penalty (per annum) - 5.00%                                         $
                                                                                               Signed
5. Interest (per annum) - 12.00%                                       $
6. BALANCE DUE                                                         $                       OfficialTitie                              Date
                                                                          Account No.                                                     Makecheckspayable
                                                                                                                                               andmailto:
                                                                        I 00003     I
                                                                       Phone Number                                                       WarrenCountyOccupational
                                                                                               I M~OT~~DEN~em                                    License
                  *                                                  I   (270) -            II   RETURN DUE ON OR BEFORE                  429East10thStreet
                                                                                                                                          BowlingGreenKY42101
                                                                                               I Month       I Day           I Year       Phone: (270)842-5805
                                                                               EJjU~ATJOI\I                                               Fax:   (270)781-2777
Indicateany11111111111111111111111111111111nameor addresschangeabove.          -"IJPAYS        I FEDIDNo.!.                               Emaii: jerry.pearson@ky
                                                                     *PLEASEMAKEA COpy OFTHISFORMFORYOURRECORDS.                          FormOCC-3PTRev.9/27/02