5
KNOX COUNTY FEE ADMINISTRATOR
NET PROFITS LICENSE FEE RETURN
Name and Address of Business
ACCOUNT NO.
CALENDAR/FISCAL YEAR ENDED
MONTH
DAY
YEAR
12
31
2016
OFFICE HOURS:
DUE DATE
8:00 am - 4:00 pm
MON - FRI
04
15
2017
TELEPHONE
Attach copy of Federal Tax Return used as
a basis of License Fee (Schedule A-Line 1)
(606) 546-8915
Phone Number
Federal ID No.
INDICATE ANY NAME OR ADDRESS CHANGE ABOVE
¨
¨
4. Did you have employees in Knox County?
Yes
No
QUESTIONS (ANSWER IN FULL)
¨
¨
5. Basis upon which tax return is prepared
Cash
Accru
al
¨
¨
¨
¨
1. Nature of Business __________________________________
6. Business Type:
C-Corp
S-Corp
Partnership
Sole-Prop.
¨
¨
2. Date Business Started in Knox County ________________
Fiduciary
Other (Specify) ________________
7. Has the IRS changed the Net Income as originally reported for any
3. If Business was Discontinued, State When ________________
¨
¨
prior year?
No
Yes (Attach Schedule of Changes for each year)
¨
¨
Dissolution
or Sale
If by sale, give Name and Address of successor
SCHEDULE A
FOR OFFICIAL USE ONLY
1. NET Business income per Federal Tax Return
2. ADD Items not Deductible
Rec'd
3. TOTAL (Line1 Plus Line 2)
4. DEDUCT Items not subject
Ck. No.
5. ADJUSTED NET BUSINESS INCOME (Line 3 less Line 4)
Amount
6. If Sch. B (line4) is used enter here AVERAGE PERCENTAGE
7. NET PROFITS subject to License Fee (Line 5 x Line 6)
Posted
8. Prior year adjustments
By
9. ADJUSTED NET PROFITS (Line 7 less Line 8) If less than "0" enter "NONE"
10. License Fee -
of line 9
1.0000%
Make checks payable and mail to:
11. Interest -
per annum.
12.00 %
KNOX COUNTY FEE ADMINISTRATOR
12. Penalty -
5% per month or portion up to 25% min $25.00
13. Total (Lines 10+11+12)
PO BOX 177
14. Less Credits - ( ) ESTIMATE ( ) OTHER
BARBOURVILLE KY 40906
15. BALANCE DUE (Line 13 less Line 14) pay this amount
Phone Number
(606) 546-8915
16. If estimate overpaid Indicate ( ) Refund or ( ) Credit
SCHEDULE B
Business Allocation percentage-Divide (Col. B) to obtain decimal Carry out at least 6 places.
ALLOCATON FACTORS
Knox County
Total
Knox Co. / Total
1. Total Gross Business Receipts
2. Total Wages, Salaries and Other Personal Service
3. TOTAL PERCENTS ..............................................................................................................................................................
4. AVERAGE PERCENTAGE (Line 3 divided by number of percents).................................................................. Enter on line 6
I hereby certify that the information, schedules, statements and exhibits filed herewith are true and correct.
Signed _____________________________________________
Title ____________________
Date _____________
THIS RETURN IS DUE ON OR BEFORE APRIL 15, FOR THE CALENDAR YEAR OR WITHIN 105 DAYS OF THE END OF YOUR FISCAL YEAR
SCNP-A Rev. 10/01/2005
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You must attach a copy of your Federal Return as applicable per KRS-67.768 (2)