Occupational License Tax Withholding Application Form - City Of Calvert City

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CITY OF CALVERT CITY
OCCUPATIONAL LICENSE TAX WITHHOLDING APPLICATION
Return to:
City of Calvert City, Tax Administrator, PO Box 36, Calvert City, KY 42029
Phone: 270-395-7138 Fax: 270-395-5554
This form is to be filled out and submitted to the above address by all businesses having employees within the
city limits of Calvert City, Kentucky and shall be used as a basis for issuance of a withholding account
identification number.
1. Business Name: __________________________________________Fed ID #:____________________________
2. Business Address: ____________________________________________________________________________
______________________________________________ Phone No. _________________ Fax ________________
3. E-Mail Address: ______________________________________________________________________________
4. Mail Address, if different from above: ____________________________________________________________
______________________________________________ Phone No. _________________ Fax _________________
5. Type of ownership: ( ) Individual; ( ) Partnership; ( ) Corporation; ( ) Non Profit; ( ) Other___________________
6. If individual, list name, address, and social security number of owner ____________________________________
____________________________________________________________ Soc. Sec. No. ______________________
7. If partnership, list name, address, and social security number of each partner
____________________________________________________________ Soc. Sec. No. ______________________
____________________________________________________________ Soc. Sec. No. ______________________
8. Nature of business: ___________________________________________________________________________
9. Do you have, or will you have, employees working in Calvert City? ( ) Yes ( ) No
10. Date that business first paid, or will pay, wages to employees in Calvert City: ____________________________
11. Name of previous owner of this business, if any: ___________________________________________________
.
12.Date you assumed ownership: __________________________________________________________________
13. Accounting period: ( ) Calendar year – Dec. 31, or ( ) Fiscal year ended _____________/______________
Month
Day
14. Other Information: __________________________________________________________________________
_____________________________________________________________________________________________
I hereby certify that all information and statements herein are true and correct.
_______________________________________/ ______________________________/ ______________________
Signature
Title
Date
_____________________________________________________________________________________________
FOR OFFICE USE ONLY
Identification No. _________________
Date account established: ________ Identification # reassigned from:_____________________
Date account closed: ___________ Identification # assigned to:_________________________
Date reassigned: ________________________________________________________________

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