Kenton County And Cities' Kentucky Employee Withholding Application Form

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KC FORM 1a REV 6/04
KENTON COUNTY AND CITIES’ KENTUCKY
EMPLOYEE WITHHOLDING APPLICATION
(FOR EMPLOYEES OF COMPANIES THAT DO NOT WITHHOLD)
This application is for use by individuals and agents of companies that do not withhold
local payroll taxes for them. If the Entity/Applicant is a Sole Proprietor, Corporation,
Partnership or Limited Liability Corporation (LLC) use KC Form 1 Rev 4/04, Kenton County
and Cities’, Kentucky Occupational License Application. Examples of the employees that
should use this form are Postal Employees and Federal Employees.
1) Name of Applicant: ______________________________________________________________
2) Social Security Number:__________________________________________________________
3) Date of Birth:___________________________________________________________________
4) Home Address:
Street Number________________________________________________________________
City_________________________________________________________________________
State & Zip Code _____________________________________________________________
5) Applicant’s Telephone #:__________________________________________________________
6) Name of Employer: ______________________________________________________________
7) Address of Employer:
Street_______________________________________________________________________
City_________________________________________________________________________
State & Zip Code _____________________________________________________________
8) Employer Telephone: ____________________________________________________________
9) City/Cities where work will be performed: ___________________________________________
10) How long worked in cities listed on line 9: __________________________________________
(11) Why employer does not withhold: ________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I HEREBY CERTIFY THAT ALL INFORMATION AND STATEMENTS HEREIN ARE TRUE AND
CORRECT. (Application will be returned if any part is incomplete)
X____________________________________________________________________________________
(Signature)
(Date)
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