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Mail Form to:
Finance Department
CITY OF WINCHESTER, KENTUCKY
City of Winchester
P O Box 4135 RETURN OF LICENSE FEE
1793
Winchester, KY 40392
1. Total Earnings Paid All Employees $____________________
BUSINESS NAME AND ADDRESS: 2. Deduct Earnings For Service Performed
Outside Winchester, Kentucky $____________________
3. Earnings Subject to License Fee $____________________
4. Actual Fee withheld at 2.0% $____________________
5. Delinquent Penalty 5% Per Month
(Max 25%) Minimum $25.00 $____________________
6. Interest 1% Per Month $____________________
Check One: 7. TOTAL $____________________
_____Quarter _____Month ______Annual I, declare, under the penalties of perjury, that this return has been
Time Period of Return _______________ examined by me and to the best of my knowledge and belief is a true,
Due Date__________________________ correct, and complete return.
____________________ _______________________________________________________ _____________________
DATE SIGNATURE TITLE
DF3 10/09
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mail Form to:
Finance Department
CITY OF WINCHESTER, KENTUCKY
City of Winchester
P O Box 4135 RETURN OF LICENSE FEE
1793
Winchester, KY 40392
1. Total Earnings Paid All Employees $____________________
BUSINESS NAME AND ADDRESS: 2. Deduct Earnings For Service Performed
Outside Winchester, Kentucky $____________________
3. Earnings Subject to License Fee $____________________
4. Actual Fee withheld at 2.0% $____________________
5. Delinquent Penalty 5% Per Month
(Max 25%) Minimum $25.00 $____________________
6. Interest 1% Per Month $____________________
Check One: 7. TOTAL $____________________
_____Quarter _____Month ______Annual I, declare, under the penalties of perjury, that this return has been
Time Period of Return _______________ examined by me and to the best of my knowledge and belief is a true,
Due Date__________________________ correct, and complete return.
____________________ _______________________________________________________ _____________________
DATE SIGNATURE TITLE
DF3 10/09
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mail Form to:
Finance Department
CITY OF WINCHESTER, KENTUCKY
City of Winchester
P O Box 4135 RETURN OF LICENSE FEE
1793
Winchester, KY 40392
1. Total Earnings Paid All Employees $____________________
BUSINESS NAME AND ADDRESS: 2. Deduct Earnings For Service Performed
Outside Winchester, Kentucky $____________________
3. Earnings Subject to License Fee $____________________
4. Actual Fee withheld at 2.0% $____________________
5. Delinquent Penalty 5% Per Month
(Max 25%) Minimum $25.00 $____________________
6. Interest 1% Per Month $____________________
Check One: 7. TOTAL $____________________
_____Quarter _____Month ______Annual I, declare, under the penalties of perjury, that this return has been
Time Period of Return _______________ examined by me and to the best of my knowledge and belief is a true,
Due Date__________________________ correct, and complete return.
____________________ _______________________________________________________ _____________________
DATE SIGNATURE TITLE
DF3 10/09
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