Employers Return Of License Fee Withheld Form - Occupational License Fee Division - City Of Owensboro

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City of Owensboro
INSTRUCTIONS ON REVERSE SIDE
1. Total Number of Owensboro Employees .....
RETURN THIS COPY WITH PAYMENT
Employers Return of License Fee Withheld
.
2. Total Wages and Other Subject Compensation Paid This Period .......
.
3. Less: Compensation Not Subject to Withholding. ......................
.
4. Earning Subject to License Fee (Line 2 Minus Line 3) ...............
Make Checks Payable to: City of Owensboro
.
5. License Fee Due (
1.33%
of line 4). ..............................
Mail to:
Occupational License Fee Division
.
P.O. Box 10003
6. Interest (
1%
Per Month) ..........................................
Owensboro, KY 42302-9003
7. Filing Penalty (
.
5%
Per Month Not to Exceed
25 %
)
$10.00 minimum . ........................................................................
Telephone Number: (270) 687-8534
.
8. Payment Penalty ( 1%
Per Month Not to Exceed 10% )
.
9. Total Amount Due (Add Lines 5,6,7 and 8) ................................
Account No.
Period Beginning
I herby certify that the information statements contained
herein and any schedules or exhibits attached are true
Period Ending
and correct to the best of my knowledge.
Due Date
Type
Signature
Title
Date

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