Boone County Fiscal Court
                                                        www.BooneCountyKy.org
                                                         2950 Washington Street
                                                             PO Box 960
                                                             Burlington, KY 41005
                                                 (859) 334-2144          (859) 334-3914 Fax
                                                         occlicense@boonecountyky.org

                                          Quarterly Withholding Tax Return for 2020
Name:                                                             Account #: ______________________________________

dba:                                                              FEIN/SSN:________________________________________
Address:                                                          For Quarter Ending: - (Circle Correct Date)
                                                                  03/31/20 due 0 /430/20      09/30/20 due 11/02/20 
City, State, Zip:                                                 06/30/20 due 073/ 1/     20 12/31/20 due 02/01/21

Total Gross Earnings of All Employees Working in Boone County
Boone County Board of Education Tax - 1/2 of 1% (.005)
                        *****No Maximum*****
1) Gross earnings subject to Boone County Board of Education tax  $
2) Multiply Line 1 - by 1/2 of 1% (.005)                          $
3) Late filing and/or Paying Penalty                              $
   ( 5% per month, maximum not to exceed 25%,minimum $25)
4) Interest Fee (1% per month, 12% per year )                     $
5) Total Board of Education Tax                                                                 $

Boone County Ordinance #07-27- 8/10 of 1% (.008)
      *****Max $63,136.00/tax of $505.09 PER EMPLOYEE*****
6) Gross earnings subject to Boone County payroll tax             $
7) Multiply Line 6 - by 8/10 of 1% (.008)                         $
8) Less any KY or Boone Local Job Assessment Program credit       $
9) Late filing and/or Paying Penalty                              $
   ( 5% per month, maximum not to exceed 25%,minimum $25)
10) Interest Fee (1% per month, 12% per year )                    $
11) Total Boone County Payroll Tax                                                            $

Boone County Mental Health Tax Ordinance #07-26- 15/100 of 1% (.0015)
      *****Max $16,666.00/tax of $25.00  PER EMPLOYEE*****
12) Gross earnings subject to Mental Health Payroll tax           $
13) Multiply Line 12 -  by 15/100 of 1% (.0015)                   $
14) Late filing and/or Paying Penalty                             $
   ( 5% per month, maximum not to exceed 25%,minimum $25)
15)Interest Fee (1% per month, 12% per year  )                    $
16) Total Mental Health Tax                                                                   $

Total remittance (add lines 5,11,16)       
Make check payable to:  Boone County Fiscal Court                                               $
Statistical Information-REQUIRED
Total Number of Employees Working in Boone County

Signed:                                                           Date:
Printed Name:                                                     Official Title:
Tax Form Prepared By:                                             Telephone Number:
Payroll Processor:                                                E-mail Contact:
I declare, under the penalties of perjury, that I have examined this document and to the best of my knowledge and belief, this is a true and accurate return.
Please notify in writing, any changes of ownership or new address by completing a Request to Change/Close Occupational License Account which 
can be found on our website at www.BooneCountyKY.org.  If you have any questions please call 859-334-2144 or email: 
OccLicense@BooneCountyKY.org
Mail your return to:
(PO Box 457, Florence, KY 41022-0457) is for returns WITH PAYMENT and                                               Form 1906
(PO Box 960, Burlington, KY 41005-0960) is for returns WITHOUT PAYMENT.