FORM
LOUISVILLE METRO REVENUE COMMISSION
3
W-
ANNUAL RECONCILIATION OF EMPLOYERS QUARTERLY RETURN
OF OCCUPATIONAL LICENSE FEES WITHHELD AND INDIVIDUAL EMPLOYEE STATEMENT
CHECK IF CHANGE IN ADDRESS IS BELOW
Name
_________________________________________________________________________________
Address
_________________________________________________________________________________
City
_________________________________
State __________
Zip ______________
Federal ID _________________________________
Phone
Ext
_____________________
_________________
ACCOUNT NUMBER
YEAR
DUE DATE
NOTE: NO REFUNDS OR CREDIT WILL RESULT FROM
ENTRIES MADE ON THIS FORM. W-1 RETURN MUST BE
AMENDED FOR REFUNDS OR CREDITS.
AMOUNT THAT SHOULD
QUARTER ENDING
HAVE BEEN PAID
ST
1.
MARCH 31
$
TH
2.
JUNE 30
$
TH
3.
SEPTEMBER 30
$
ST
4.
DECEMBER 31
$
5.
TOTAL QUARTERLY TAXES THAT SHOULD HAVE BEEN PAID (Sum of Lines 1 - 4)
$
6.
TOTAL TAXES WITHHELD PER SCHEDULE OF EMPLOYEES' WAGES ATTACHED
$
7.
DIFFERENCE BETWEEN LINE 5 & LINE 6
$
W-2’s filed electronically/magnetically with the Louisville Metro Revenue Commission
___________________________________________________
______________________________
AUTHORIZED SIGNATURE
DATE
INSTRUCTIONS FOR ANNUAL RECONCILIATION OF WITHHOLDING TAXES
Wage and Tax Statements should be submitted for only those employees that earned wages while working in Louisville Metro,
Kentucky. If any quarter(s) has been over or underpaid, amended Form W-1's must be attached to this Form W-3, If any
additional tax is owed (Line 7 of this form), please submitted your check along with these forms.
This reconciliation form must be filed with the LOUISVILLE METRO REVENUE COMMISSION, 101 South 8th Street, Louisville,
Kentucky 40202, on or before January 31st. Employee W2 forms can be forwarded to the Metro Revenue Commission in IRS
format, either electronically through the web or magnetically. Visit our website, at , for a current list of
acceptable magnetic media. If submitted in this manner, please check the box ‘W2’s filed electronically/magnetically’
above and return to our office.
W-2 information and the Annual Reconciliation (Form W-3) should be mailed separately from the 4th quarter withholdings tax
return. If no W-2 will be filed, complete the Schedule of Employees’ Wages on the reverse side of this return.
MAILING ADDRESS: P.O. BOX 35410 • LOUISVILLE, KENTUCKY 40232-5410
Telephone: (502) 574-4860 • • Fax: (502) 574-4818 • • TDD: (502) 574-4811
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