Boone County Fiscal Court 
                                             www.BooneCountyKy.org 
                                             2950 Washington Street 
                                             PO Box 960 
                                               Burlington, KY  41005 

                                   Annual Reconciliation Form for 2020
Name:                                                                    Acct #:_____________________ 

dba:                                                                     FEIN/SSN:__________________ 

Address:                                                                 Due Date:  March 1, 2021
City, State, Zip:                                                         You must attach copies of W-2 
                                                                         Forms or supporting documents 
Boone County Board of Education Tax Withheld 
                  Wages                               Tax Withheld/Paid                # employees _________ 
1 stQuarter       $______________                     $______________ 
2 ndQuarter       $______________                     $______________ 
3 rdQuarter       $______________                     $______________ 
4thQuarter        $______________                     $______________ 
TOTALS            $_______________                    $______________ 
Total W-2 Wages Subject To This Tax per W-2’s $______________________ X .005 = $___________________ 
        A.  Difference between Quarterlies Remitted and W-2 Totals $__________________ 
Boone County Ordinance Tax #07-27 Withheld 
                  Wages                               Tax Withheld/Paid                # employees _________ 
1 stQuarter       $______________                     $______________ 
2 ndQuarter       $______________                     $______________ 
3 rdQuarter       $______________                     $______________ 
4 thQuarter       $______________                     $______________ 
TOTALS            $______________                     $______________ 
Total W-2 Wages Subject To This Tax per W-2’s $___________________ X .008 = $______________________ 
        B.  Difference between Quarterlies Remitted and W-2 Totals $ ________________ 
Boone County Mental Health Tax #07-26 
            Withheld Wages                            Tax Withheld/Paid                # employees:_________ 
1 stQuarter       $______________                     $______________ 
2 ndQuarter       $______________                     $______________ 
3 rdQuarter       $______________                     $______________ 
4 thQuarter       $______________                     $______________ 
TOTALS            $______________                     $______________ 
Total W-2 Wages Subject To This Tax per W-2’s$___________________ X .0015  = $_____________________ 
        C.  Difference between Quarterlies Remitted and W-2 Totals $ ________________ 
Summary:  (A) + (B) + (C)   _________________________                # W-2’s attached 
If difference is less than $5.00, nothing is to be paid or will be refunded.  If greater than $5.00, please issue payment as 
appropriate to avoid applicable penalties.  If a refund is due, you must amend the appropriate quarterly return to obtain a 
refund. 
Signature:                                              Date: 
Telephone # :                                           E-MAIL:                                     Form 1206