Kentucky Dual DIstrict
Form                                                                                                                     For Year Ending                      /           / 20
     OL-D                    Occupational License Fee Return                                       REV_V3.0.2.s4_02112016
Tax District Name 1 (See instructions)

Tax District Name 2 (See instructions)

Tax District Address

                                                                                                   Department Use Only—Do not write or staple in this space. 
Taxpayer Name                                                                                                                                          Filing Status:
                                                                                                                         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

                                                                                                                                                  Amended
Tax District Account Number                                                                       Method of Accounting                            Fed ID Change (Complete Line F) 
                                                                                                                                               Name Change
                                      Fed ID        SSN                                            Accrual         Cash                           Address Change
                                                                                                                         Check all that apply     Final (Complete Line G)

A Principal business activity                                                                                                                 NAICS Code:

                                                                                                                                                                     YES NO
B Did you have employees for Tax District 1 during the past year?
  Did you have employees for Tax District 2 during the past year?                                                                                                    YES NO

C Did you make payments in the sum of $600.00 or more for services rendered in either 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 Fed ID change, 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
                                                                                                                 -
                                                                                                                                                                                  Page: 1

Taxpayer Name

Account Number                                         For Year Ending
                                                        /              / 20
                                                                                                      Department Use Only—Do not write or staple in this space. 
                                                                                       TAX DISTRICT 1               TAX DISTRICT 2 
Section 1:       Occupational License Fee Calculation

                                                                                       No Activity                               No Activity

1  Enter Adjusted Gross Receipts from                                            $                    .00   $                                                   .00
   Schedule G or Adjusted Net Profit from Schedule N
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   $                                                   .00
                                                                             %
   License Fee for District 2                             .                                                 $
4  License Fee for District 1                             .                  %   $                    .00                                                       .00
   (Line 3) X tax rate of % (See local Instructions) 
5    If tax district has a minimum tax, enter here. (See local Instructions)     $                    .00   $                                                   .00

   If tax district has a maximum tax, enter here. (See local Instructions)
6                                                                                $                    .00   $                                                   .00
               a.  If the tax district does not have a 
7
   Sub               minimum or maximum tax, enter value from line 4.            $                          $                                                   .00
   Total       b.  If line 4 is less than 5, enter line 5 here.                                       .00
   Amount:     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 district, e.g. Laurel County)                                .00                                                       .00
9  Subtotal: Subtract line 8 from line 7.  Cannot be less than zero.             $                          $
                                                                                                      .00                                                       .00

10 If applicable enter Line 6 from Schedule W.                                   $                    .00   $                                                   .00

11 Subtotal:  Add Line 9 and Line 10.                                            $                    .00   $                                                   .00

12 Enter estimated payments and/or prior year credits.                           $                    .00   $                                                   .00

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

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

15 Interest - If applicable.  (See local Instructions)                           $                    .00   $
                                                                                                                                                                .00

16 Additional fees due:                                                          $                    .00   $
                                                                                                                                                                .00
STOP: See local instructions for additional 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 local instructions)      $                    .00                                                       .00
                                                                               Credit to next year:          Credit to next year:
18 Overpayment.  If Line 17 is less than zero enter application                  $                    .00   $                                                   .00
                                   of overpayment here.
                                                                               Refund:                       Refund:
                                                                                 $                    .00   $                                                   .00

                                                                                                                                                                Page: 2

Taxpayer Name

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.
                                                                                                                                               TAX DISTRICT 1           TAX DISTRICT 2

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

                                                              2a     Payroll within the Tax District
                                                                                                                                        $                     .00   $                                              .00

                                                                                                                                                                    $
                                                              2b     Total Payroll everywhere                                           $                     .00                                                  .00

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

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

                                                              4 Apportionment Percentage - If both Lines 1(b) and 2(b)                              .         %                                            .       %
                                                                are greater than zero, divide entry on Line 3 by 2. 
                                                                Enter here. If either Line 1(b) or Line 2(b) is zero, enter the 
                                                                amount from Line 3 here. 
                                                                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                                                                                                                                Print Name

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

                                                                                         You must attach all applicable federal returns and schedules.

                                                                                                                                                                                                                    Page: 3

Taxpayer Name

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

Schedule N:                    Calculation of Adjusted Net Profit

          Some Tax Districts do not allow multiple individual schedules               TAX DISTRICT 1         TAX DISTRICT 2 
   Note:  on the same worksheet.  (See Instructions).  Applies to lines 1-6. 
*         Enter amounts in both column if applicable.

    If an Individual, enter non-employee compensation as reported on Form 
1   1099-MISC and reported as other income on Federal Form 1040                                            $
* (Attach Form 1040 and applicable schedules)                                       $                .00                                        .00
2 * If an Individual, enter net profit or (loss) from Federal Schedule C of Form    $                .00   $
    1040 (Attach Form 1040 and applicable schedules)                                                                                            .00

3   If an Individual, enter capital gain from Federal Form 4797 or Form                                    $
*   6252 reported on Schedule D on Form 1040 (Attach Federal Schedules)             $                .00                                        .00
4   If an Individual, enter rental income or (loss) from Federal Schedule E                               $
*   of Form 1040 (Attach Form 1040 and applicable schedules)                        $                .00                                        .00
5 * If an Individual, enter farm net profit or (loss) from Federal Schedule F       $                .00   $
    of Form 1040 (Attach Form 1040 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                                    $                .00                                        .00
    (Attach Form 4797 and applicable schedules)
7   If a Partnership, enter ordinary income or (loss) from Federal Form 1065        $                .00   $
    (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                             $                .00   $                                    .00
    (Attach applicable Federal Schedules)
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   $                                    .00

10  If a Partnership or S Corporation, enter additions from Schedules K             $                .00   $
    on Form 1065 or Form 1120S                                                                                                                  .00
11  If a Corporation, enter net operating loss deducted on Form 1120                $                .00   $
                                                                                                                                                .00
12  Total Income.  Add Line 1 through Line 11.     (     See Note Above)            $                      $
                                                     *                                               .00                                        .00

13  If a Partnership or S Corporation,                                              $                .00   $
    enter subtractions from Schedule K of Form 1065 or Form 1120S                                                                               .00

14  Alcoholic Beverage Sales Deduction (Line 5 from Schedule A)                     $                .00   $
                                                                                                                                                .00

15  Other Adjustments - Attach Schedule (See Instructions)                          $                .00   $
                                                                                                                                                .00
16  Total Deductions.  Add Line 13 through Line 15                                  $                .00   $
                                                                                                                                                .00
                                                                                                           $
17  Adjusted Net Profit.                                                            $                .00
    Subtract Line 16 from Line 12.  Enter here and on Page 2, Line 1                                                                            .00

                                                                                                                                                Page: 4

Taxpayer Name

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                TAX DISTRICT 1         TAX DISTRICT 2 
*         on the same worksheet.  (See Instructions).  Applies to lines 1-5.

1  If an Individual, enter non-employee compensation as reported on Form 
 * 1099-MISC and reported as other income on Federal Form 1040                      $                .00   $                                    .00
   (Attach Form 1040 and applicable schedules)
2  If an Individual, enter gross receipts from Federal Schedule C of Form 
 * 1040 (Attach Form 1040 and applicable schedules)                                 $                .00   $                                    .00
3  If an Individual, enter capital gain from Federal Form 4797 or Form 6252 
 * reported on Schedule D on Form1040 (Attach Federal Schedules)                    $                .00   $                                    .00

4  If an Individual, enter rental gross receipts from Federal Schedule E of Form                           $
 * 1040 (Attach Form 1040 and applicable schedules)                                 $                .00                                        .00
   If an Individual, enter farm gross receipts from Federal Schedule F of Form  
5* 1040 (Attach Form 1040 and applicable schedules)                                 $                .00   $                                    .00

6  If a Partnership, enter gross receipts from Federal Form 1065                    $                     $                                     .00
   (Attach Form 1065 and applicable schedules)                                                       .00
7  If a Corporation, enter gross receipts from Federal Form 1120 per Federal        $                     $
   Form 1120S (Attach 1120 or 1120S and applicable Federal Schedules)                                .00                                        .00
8  If a Corporation, enter gross receipts from "Gross Rents" from Fed. Form 1120    $                     $
   (Attach Federal Form 1120)                                                                        .00                                        .00
9  Gross Receipts from rental activity of a Partnership or S Corporation            $                     $
   (Attach Federal Form 8825)                                                                        .00                                        .00
                                                                                                          $
10 Total Gross Receipts.  Add Line 1 through Line 9                                 $                .00                                        .00
                                                                                                          $
11 Gross Alcoholic Beverage Sales within the Tax District                           $                .00                                        .00
                                                                                                          $
12 Sales Tax and Excise Tax included in Gross Receipts                              $                .00                                        .00
13 Returns and Allowances Deduction                                                 $                .00   $                                    .00

14 Total Deductions  Add Lines 11 through Line 13                                   $                .00   $                                    .00
15 Adjusted Gross Receipts. Subtract Line 14 from Line 10.  
   Enter here and on Page 2, Line 1.                                                $                .00   $                                    .00

                                                                                                                                                Page: 5

Taxpayer Name

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)
                                                                                                TAX DISTRICT 1                                    TAX DISTRICT 2 

1 Total Kentucky Alcoholic beverage sales                                            $                                        $
                                                                                                                          .00                                            .00

2 Total sales                                                                        $                                        $
                                                                                                                          .00                                            .00

3 Alcoholic beverage percentage: Line 1 divided by Line 2                                         .                       %                               .              %

4 Adjusted Gross Receipts before Alcoholic Beverage Deduction                        $                                        $
  (Line 12 minus the sum of Line 13 and Line 15 from Schedule N.  See       note).                                        .00                                            .00
                                                               *
5 Alcoholic Beverage Deduction                                                       $                                        $
  Multiply Line 3 by Line 4.  Enter Schedule N Line 14.                                                                   .00                                           .00

  Note:  This deduction may be taken only if the business had a profit.
*
Schedule W:                    Calculation of Gross Salaries, Wages, Tips, etc. (For Individual Filers Only)
                                                                                                TAX DISTRICT 1                                    TAX DISTRICT 2 

1 Gross salaries, wages, tips, etc. reported on the Federal Form W-2 from 
  which no occupational taxeswere withheld, plus deferred                   $                                  .00            $
  compensations from 401 (k), 403 (b), or 457 plans.                                                                                                                     .00
2 Related employee business expenses per Federal Form 2106  
  (Attach Form W-2 and Form 2106 unless already provided)                   $                                  .00            $                                          .00

3 Line 1 minus Line 2                                                       $                                  .00            $                                          .00
                                                                          Total Days              Total Days                Total Days                      Total Days  
                                                                          Worked in             / Worked                    Worked in             /         Worked 
                                                                          Locality                Everywhere                Locality                        Everywhere
4 Enter percentage of wages earned in the tax districts
                                                                                                .              %                                          .              %

5 Multiply Line 3 by Line 4                                                 $                                  .00            $                                         .00

                                                                          Multiply                                          Multiply  
                                                                          Line 5 X                                          Line 5 X 
                                                                          tax rate of           .              %            tax rate of                   .             %
                                                                          (See Instructions)  Enter on Line 10 Section 1. (See Instructions)  Enter on Line 10 Section 1.

6 Tax Due:                                                                  $                                  .00            $                                         .00

                                                                                                                                                                         Page: 6