Employer'S Return Of License Fee Withheld Form - Shelby County, Kentucky

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SHELBY COUNTY, KENTUCKY
EMPLOYER'S RETURN OF LICENSE FEE WITHHELD
*lf no wages were paid this period, mark none and return this form.
1.
Total salaries, wages, commissions and
5.
Add Penalty late payment 2%
other compensation paid to all
$___________
per month or portion
employees for services within Shelby
$________
County (excluding the City of Shelbyville)
6.
Add Interest 10% per annum
$___________
$________
7.
Net Payment due lines (4,5
2.
Employee License fee withheld @ 1%
$___________
and 6)
$________
3.
Credits (attach explanation)
I hereby certify that the information,
$________
4.
Balance due
schedules, statements and exhibits
filed herewith are true and correct.
Signature:
_____________________________
Official Title:
_____________________________
Make checks
Employer
Account
For Period Ending
payable and mail
Number
to:
Month
Day
Year
Shelby County
Occupational
License Fee
Administrator
215
Washington
Street
Indicate any name or address change
Return Due on or Before April 30,
Shelbyville, KY
above.
July 31, October 31, January 31
40065
*Please make a copy of this form for
502-633-7685
your records.

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