EMPLOYEE / EMPLOYER QUARTERLY  

                                                RETURN  OF LICENSE FEE WITHELD  

                                                City of Hillview, 283 Crestwood Lane, Louisville, Kentucky 40229 
                                                          Office: (502) 957-5280       Fax: (502) 955-5673 
                                                                                                           
Business Name:  _______________________________________________________________________ 

Address:        _______________________________________________________________________ 

City:           _______________________________________________________________________ 

State:          __________________________                Zip:  _____________________________ 

Account Number: __________________________                Email: _____________________________ 

For Quarter Ending:__________________________             Year:  _____________________________ 

Payment is due within one month from above date     (reference: For Quarter Ending). If a receipt is desired, 
enclose a self-addressed and stamped envelope. 

Remit To:   City of Hillview 
            283 Crestwood Lane 
            Louisville, KY 40229 
 
*If no wages were paid this Quarter, mark “NONE”, sign and return with an explanation. 
 
1.    Total earnings paid all employees (*)               ______________________________ 

2.    Less earnings for outside services rendered         ______________________________ 

3.    Taxable earnings (Line 1 minus Line 2)              ______________________________ 

4.    Actual tax withheld in Quarter at 1.8%              ______________________________ 

5.    Penalty (10% of Line 4)                             ______________________________ 

6.    Total (include penalty if due)                      $ _____________________________ 

      I hearby certify that all of the information and statements contained herein are true and accurate. 
 
____________________________________              _________________________          __________________ 
Signature                                         Title                              Date