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0.5% Occupational License Tax Application For Amnesty - Board Of Education Of Fayette County

Board of Education of Fayette County

0.5% Occupational License Tax

Application for Amnesty

(Application must be completed and returned with payment on or before November 14, 2003.)

Taxpayer Information

Taxpayer or business name

Local account #

Mailing address

City

State

Zip

Street address (if different from above)

City

State

Zip

Federal ID # or SS #

Business phone

Home phone

Check the appropriate box:

Individual/ Sole Proprietor;

LLC/Sole Proprietor;

Partnership;

LLC/Partnership;

Corporation;

S Corporation;

Non-Profit;

Other

Schedule of Tax Periods Past Due –

Use this schedule to list tax periods previously not reported, previously reported but in

need of amendment, previously reported and not paid in full, or to list outstanding tax notices. Attach all supporting documentation

and tax returns. Amnesty is a waiver of penalties and interest only for the tax forms/periods listed below.

Tax Type

Tax Period

Tax Due

Total Occupational License Tax Due

Blank tax forms may be obtained at

Declaration/Signature

Under penalties of perjury, I declare that I have examined this form, including any accompanying returns and schedules and to the best of my knowledge and

belief they are true, correct and complete. I agree to satisfy all of the requirements for amnesty, and I understand that if all requirements are not satisfied, my

request for amnesty will be denied and approval will be deemed revoked. I understand that my payment of taxes pursuant to this amnesty program constitutes

a waiver of any right to file a claim for refund or an amended return for refund, or seek an administrative review, administrative hearing or appeal.

____________________________________________________

_______________

Signature of Licensee

Date

____________________________________________________

_______________

Signature of Individual Preparing Application

Date

Make checks payable to Fayette County Public Schools (or FCPS)

Mail to: Fayette County Public Schools

Tax Collection Office