Registration Form - Taylor County Fiscal Court

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REGISTRATION FORM
TAYLOR COUNTY FISCAL COURT
PHONE(270) 465-9760
DIVISION OF OCCUPATIONAL TAX
FAX # (270) 465-0380
P.O. BOX 529
occtax@taylorcounty.us
CAMPBELLSVILLE KY 42719-0529
Every business or individual subject to the Occupational License Fee is required to complete this application and return it to the Tax
Administrator. (OAG-85-1) Kentucky Attorney General states that the Occupational Tax Office must let persons inspect records
pertaining to principal business location, address and telephone number of each person or entity (trade name-if different) and nature of
business of the person or entity filing the application.
ANSWER ALL APPLICABLE QUESTIONS, SIGN, AND RETURN
FOR BUSINESS USE ONLY
Business or Trade Name: ______________________________________________________________________________________
Physical Address: _____________________________________________________________________________________________
City, State, Zip: ______________________________________________________________________________________________
LOCAL CONTACT PERSON:_________________________________________________________________________________
Telephone #: (_______)____________________________________ Fax #: (_______)___________________________________
ADDRESS TO RECEIVE QUARTERLY & ANNUAL FORMS: ___________________________________________________
City, State, Zip: ______________________________________________________________________________________________
CONTACT PERSON:________________________________________________________________________________________
Telephone #: (_______)____________________________________ Fax #: (_______)___________________________________
Date operations started in Taylor County:_______________________ Number of Employees__________Seasonal_____Yes_____No
st
nd
rd
th
In which quarter will employees occur? ______1
______2
______3
______4
NATURE OF BUSINESS:
SELECT BUSINESS TYPE:
Fiduciary
Corporation
S-Corporation
Partnership
Individual
Farm
Religious/Non-Profit
Proprietorship
Other (please specify) ___________________________
Federal Tax I.D.#______________________________________ Accounting Period______Calendar Yr (Jan. through Dec.) OR
*If none, use Social Security #
______Fiscal Year(Month:
)
Previous Owner’s Name/Address (if applicable): ____________________________________________________________________
____________________________________________________________________________________________________________
INDIVIDUAL USE ONLY: (EMPLOYER DOES NOT WITHHOLD TAX, OR YOU ARE AN “INDEPENDENT”)
Name: _______________________________________________Address: _______________________________________________
City, State, Zip: ______________________________________________________________________________________________
SOCIAL SECURITY NUMBER: _______________________________________________________________________________
Business Phone: (_______)_______________________________ Home Phone : (_______)_________________________________
Business & Address where you work :_____________________________________________________________________________
How employed?: _____________________________________________________________________________________________
ATTENTION CONTRACTORS: YOU MUST PROVIDE LIST OF SUB-CONTRACTORS, INCLUDING ADDRESSES.
ATTENTION PARTNERSHIPS: YOU MUST PROVIDE LIST OF PARTNERS, INCLUDING ADDRESSES.
(IN EITHER CASE, ATTACH A SEPARATE SHEET IF NECESSARY)
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true,
correct and complete.
Please Print Name: ____________________________________________________________________________________________
SIGNATURE: _______________________________________________________________________________________________
Date: ____________________________________________________________________
register2007

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