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

                                   Annual Reconciliation Form for 2018
Name:                                                                   Acct #:_____________________ 

dba:                                                                    FEIN/SSN:__________________ 

Address:                                                                Due Date:  February 28, 201 9 
                                                                        You must attach copies of W-2 
City, State, Zip: 
                                                                        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 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 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