Kentucky Local Standard
Form                                                                                               Do Not Staple.                                                 /      /20
                                                                                                   Print or Copy Single Side Only.
  OL-SSingle Tax District    Occupational License Fee Return                                                                                                   For Year Ending
Tax District Name (See instructions)

Tax District Address

                                                                                                   Department Use Only—Do not write or staple in this space. 
Taxpayer Name
                                                                                                                                                  Filing Status:
Trade Name
                                                                                                                       Filing Status Change?                 YES        NO
Address
                                                                                                                                            Individual Resident
Address 2                                                                                                                                   Individual Non-Resident
                                                                                                                                            Corporation
City                                                           State                      Zip Code                                          Partnership
                                                                                                               -                            S Corp
                                                                                                                       Check one box only   Other
                                                                                                                                            No Activity
Tax District Account Number                                                                       Method of Accounting                      Amended
                                                                                                                                            Fed ID Change (Complete Line F) 
                                    Fed ID             SSN                                         Accrual       Cash                       Final (Complete Line G)
                                                                                                                                             Name Change
                                                                                                                       Check all that apply Address Change

A Principal business activity                                                                                                                NAICS Code:

B Did you have employees during the past year?                                                                         YES NO
  Number of employees who worked in this locality

C Did you make payments in the sum of $600.00 or more for services rendered in this locality to any individual         YES NO
  other than an employee?  If "YES", submit copy of 1099s to local tax district.
                                                                                                                       YES NO
D Did you file a consolidated C - Corporation federal return?  If "YES", see instructions.

E During the past year, did IRS change or propose to change net income reported for that year or                       YES NO
  any prior year?  If "YES", see instructions.
  Which year(s)?

F If Federal ID changed, list the name of new entity :                                                                                            Ownership Change Date:
                                                                                                                                                        /           / 20

G If final return, state reason for discontinuance :
                                                                                                                                                  Discontinuance Date:
     List successor if sold:                                                                                                                            /           / 20

H List Principal Administrative Officer's Name, Address, and Social Security Number:
Name                                                                                                                                         SSN:

Address

Address 2

City                                                           State                      Zip Code
                                                                                                               -

Rev. Date - 07.08.16                                                                                                                                                        Page: 1

Taxpayer Name

Tax District Name

Tax District Account Number           For Year Ending
                                                     /  / 20
                                                                                                                           Department Use Only—Do not write or staple in this space. 

Section 1:           Occupational License Fee Calculation

1  Enter Adjusted Gross Receipts from Schedule G or Adjusted Net Profit from Schedule N                                      $                                                       .00
2  Enter apportionment percentage or 100% from page 3, Section 2, Line 4.
                                                                                                                                                   .                                 %
3  Enter Taxable Gross Receipts or Net Profit (Line 1 X Line 2)                                                              $
                                                                                                                                                                                     .00
4  License Fee (Line 3) X tax rate of                                                                %  (See Instructions)   $
                                                    .                                                                                                                                .00
5  If tax district has a minimum tax, enter here. (See Instructions)                                                         $                                                       .00
6  If tax district has a maximum tax, enter here. (See Instructions)                                                         $                                                       .00

   Sub Total Amount:                                                                                                         $                                                       .00
7
   a.  If the tax district does not have a minimum or maximum tax, enter value from line 4. 
   b.  If line 4 is less than 5, enter line 5 here. 
   c.  If line 6 is greater than zero and line 4 is greater than line 6, enter line 6 here.
8  Enter Non-Refundable Credits.  (See Instructions for those specific districts, e.g. Laurel County)                        $
                                                                                                                                                                                     .00
9  Subtotal: Subtract line 8 from line 7.  Cannot be less than zero.                                                         $
                                                                                                                                                                                     .00
10 If applicable enter Line 6 from Schedule W.                                                                               $
                                                                                                                                                                                     .00
11 Subtotal:  Add Line 9 and Line 10.                                                                                        $
                                                                                                                                                                                     .00
12 Enter estimated payments and/or prior year credits.                                                                       $                                                       .00

13 Occupational License Fee Due. (Subtract line 12 from line 11)                                                             $
                                                                                                                                                                                     .00

14 Penalties - If applicable.  (See Instructions)                                                                            $                                                       .00

15 Interest - If applicable.  (See Instructions)                                                                             $
                                                                                                                                                                                     .00
16 Additional fees due:                                                                                                      $
                                                                                                                                                                                     .00
STOP: Additional fees may apply per local tax district.  See instructions for additional 
      tax district amounts due, such as next year minimum, privilege taxes, or regulatory fees

17 Total Amount Due.  Add lines 13, 14, 15, and 16 (See above)                                                               $                                                       .00
                                                                                                                               Credit to next year:
18 Overpayment.  If Line 17 is less than zero enter application of overpayment here.                                         $                                                       .00
                                                                                                                               Refund:
                                                                                                                             $                                                       .00

Rev. Date - 07.08.16                                                                                                                                                                 Page: 2

Taxpayer Name

Tax District Name

Tax District Account Number                                                                    For Year Ending
                                                                                                      /            / 20
                                                                                                                                                         Department Use Only—Do not write or staple in this space. 

Section 2: Apportionment Factors                                                                     Calculation of Apportionment Percentage - A taxpayer whose business activities were conducted in 
                                                                                                     more than one tax district must complete this section.

                                                              1a     Sales/Gross Receipts within the Tax District                                                            $                                           .00

                                                              1b     Total Sales/Gross Receipts everywhere
                                                                                                                                                                             $                                           .00
                              Sales Factor 
                                           (See Instructions) 1c     Divide Line 1a by Line 1b                                                                                             .                             %

                                                              2a     Payroll within the Tax District                                                                         $                                           .00

                                                              2b     Total Payroll everywhere                                                                                $                                           .00

               Payroll Factor 
                                           (See Instructions) 2c     Divide Line 2a by Line 2b                                                                                             .                             %

                                                              3 Total Percentages (add line 1c + 2c)                                                                                       .                             %

                                                                Enter here. If either Line 1(b) or Line 2(b) is zero, enter the amount from Line 3 here. 
                                                              4 Apportionment Percentage - If both Lines 1(b) and 2(b) are greater than zero, divide entry on Line 3 by 2.                 .                             %
                                                                EXAMPLE: "22.12345%"  
                                                                 
Section 3:                                                       Signature (return must be signed)
I hereby certify that the statements made herein and in any supporting schedules are true, correct and complete to the best of my knowledge under penalty of perjury.

Print Name                                                       PREPARER                                                    Print Name                                    TAXPAYER

Preparer's Signature                                                                                                         Taxpayer's Signature

Firm Name                                                                                                                    Title

TIN                                                                                                  Date:                   SSN                                                   Date:
                                                                                                            /           / 20                                                                /                        / 20
Address                                                                                                                      Address

City                                                                                  State          Zip Code                City                                          State   Zip Code
                                                                                                                  -                                                                                                -
Phone Number                                                                                                                 Phone Number

                                                                                                                             Do you want to allow your tax preparer to discuss this                                 YES  NO
                                                                                                                              return with the tax district agency?  

                                                                                               You must attach all applicable federal returns and schedules.

Rev. Date - 07.08.16
                                                                                                                                                                                                                         Page: 3

Taxpayer Name

Tax District Name

Tax District Account Number              For Year Ending
                                                 /          / 20
                                                                                                    Department Use Only—Do not write or staple in this space. 

Schedule N:                     Calculation of Adjusted Net Profit

   Note:  Some tax districts do not allow multiple individual schedules on the same worksheet.  (See Instructions).  Applies to lines 1-6.
*

1    If an Individual, enter non-employee compensation as reported on Form 1099-MISC and reported as other 
   * income on Federal Form 1040 (Attach Form 1040 and applicable schedules)                                                 $                                .00
2    If an Individual, enter net profit or (loss) from Federal Schedule C of Form 1040 (Attach Form 1040 and 
   * applicable schedules)                                                                                                   $                                .00
3    If an Individual, enter capital gain from Federal Form 4797 or Form 6252 from the sale of property used in a trade or 
   * business reported on Schedule D on Form 1040 (Attach Federal Schedules)                                                 $                                .00
4    If an Individual, enter rental income or (loss) from Federal Schedule E of Form 1040 (Attach Form 1040 
   * and applicable schedules)                                                                                               $                                .00
     If an Individual, enter farm net profit or (loss) from Federal Schedule F of Form 1040 (Attach Form 1040 
5  * and applicable schedules)                                                                                               $                                .00
6    If an Individual, enter ordinary gain or (loss) on the sale of property used in a trade or business per Federal 
   * Form 4797 (Attach Form 4797 and applicable schedules)                                                                   $                                .00
7    If a Partnership, enter ordinary income or (loss) from Federal Form 1065 (Attach Form 1065 and applicable 
     schedules)                                                                                                              $                                .00
8    If a Corporation, enter taxable income or (loss) from Federal Form 1120 or ordinary income or (loss) 
     per Federal Form 1120S (Attach applicable Federal Schedules)                                                            $                                .00
9    State income taxes and occupational license fees deducted on the Federal Schedules C, E or F, or Federal 
     Form 1065, 1120 or 1120S                                                                                                $                                .00

10   If a Partnership or S Corporation, enter additions from Schedules K on Form 1065 or Form 1120S                          $
                                                                                                                                                              .00
11   If a Corporation, enter net operating loss deducted on Form 1120
                                                                                                                             $                                .00
12   Total Income.  Add Line 1 through Line 11. (     See Note Above)
                                                    *                                                                        $                                .00
13   If a Partnership or S Corporation, enter subtractions from Schedule K of Form 1065 or Form 1120S
                                                                                                                             $                                .00
14   Alcoholic Beverage Sales Deduction (Line 5 from Schedule A)
                                                                                                                             $                                .00
15   Other Adjustments - Attach Schedule (See Instructions)
                                                                                                                             $                                .00

16   Total Deductions.  Add Line 13 through Line 15                                                                          $
                                                                                                                                                              .00
17   Adjusted Net Profit.  Subtract Line 16 from Line 12.  Enter here and on Page 2, Line 1
                                                                                                                             $                                .00

Rev. Date - 07.08.16
                                                                                                                                                              Page: 4

Taxpayer Name

Tax District Name

Tax District Account Number                 For Year Ending
                                             /              / 20
                                                                                                     Department Use Only—Do not write or staple in this space. 

Schedule G:                   Calculation of Adjusted Gross Receipts

   Note: Some tax districts do not allow multiple individual schedules on the same worksheet.  (See Instructions).  Applies to lines 1-5.
*

   If an Individual, enter non-employee compensation as reported on Form 1099-MISC and reported as other 
1  income on Federal Form 1040 (Attach Form 1040 and applicable schedules)                                                    $                                .00
  *
   If an Individual, enter gross receipts from Federal Schedule C of Form 1040 (Attach Form 1040 and 
2 * applicable schedules)                                                                                                     $                                .00
3   If an Individual, enter capital gain from Federal Form 4797, Form 6252, and/or Schedule D for property used in a trade    $                                .00
  * or business. (Attach Federal Schedules)
   If an Individual, enter rental gross receipts from Federal Schedule E of Form 1040 (Attach Form 1040 
4 * and applicable schedules)                                                                                                 $                                .00
5  If an Individual, enter farm gross receipts from Federal Schedule F of Form 1040 (Attach Form 1040 
  * and applicable schedules)                                                                                                 $                                .00
6  If a Partnership, enter gross receipts from Federal Form 1065 (Attach Form 1065 and applicable                             $                                .00
   schedules)
7  If a Corporation, enter gross receipts from Federal Form 1120 per Federal Form 1120S 
   (Attach 1120 or 1120S and applicable Federal Schedules)                                                                    $                                .00

8  If a Corporation, enter gross receipts from "Gross Rents" from Federal Form 1120 (Attach Federal Form 1120)                $
                                                                                                                                                               .00
   Gross Receipts from rental activity of a Partnership or S Corporation 
9  (Attach Federal Form 8825 and other applicable schedules)                                                                  $                                .00

10 Total Gross Receipts.  Add Line 1 through Line 9                                                                           $                                .00

11 Gross Alcoholic Beverage Sales within the Tax District                                                                     $                                .00

12 Sales Tax and Excise Tax included in Gross Receipts                                                                        $                                .00

13 Returns and Allowances Deduction                                                                                           $                                .00

14 Total Deductions  Add Lines 11 through Line 13                                                                             $                                .00

15 Adjusted Gross Receipts. Subtract Line 14 from Line 10. Enter here and on Page 2, Line 1.                                  $                                .00

Rev. Date - 07.08.16
                                                                                                                                                               Page: 5

Taxpayer Name

Tax District Name

Tax District Account Number           For Year Ending
                                         /                 / 20
                                                                                                      Department Use Only—Do not write or staple in this space. 

Schedule A:                      Calculation of Alcoholic Beverage Deduction (for use by Schedule N filers)

1 Kentucky Alcohol beverage sales                                                                                     $                                           .00

2 Total sales                                                                                                         $                                           .00

3 Alcoholic Beverage percentage: Line 1 divided by Line 2                                                                                                       . %
                                                                   This deduction may be taken only if 
  Line 12 minus the sum of Line 13 and Line 15 from Schedule N.                                                                                                   .00
4 Adjusted Net Profit before Alcoholic Beverage Deduction                                 the business had a profit   $

5 Alcoholic Beverage Deduction                                                                                        $                                           .00
  Multiply Line 3 by Line 4.  Enter Schedule N Line 14.

Schedule W:                      Calculation of Gross Salaries, Wages, Tips, etc.                                                   (For Individual Filers Only)

1 Gross salaries, wages, tips, etc. reported on the Federal Form W-2 from which no occupational taxes                 $                                           .00
  were withheld, plus deferred compensation from 401 (k), 403 (b), or 457 plans.

2 Related employee business expenses per Federal Form 2106 (Attach Form W-2 and Form 2106 unless already              $
  provided)                                                                                                                                                       .00

3 Line 1 minus Line 2                                                                                                 $                                           .00

4 Total Days Worked in Locality                            / Total Days Worked Everywhere                                                                       . %

5 Multiply Line 3 by Line 4                                                                                           $                                           .00

6 Multiply Line 5 by tax rate of      .                          % (See Instructions)  Enter on Line 10 Section 1.    $                                           .00

Rev. Date - 07.08.16                                                                                                                                              Page: 6