PULASKI COUNTY COUNTY OCCUPATIONAL TAX
NET PROFIT LICENSE FEE RETURN
***This form must be completed in its entirety. If Federal I.D. or Social Security Number is omitted, this form will be
returned to you. If address change applies, you must check the address change box.***
FEDERAL I.D. OR SOCIAL
CHECK IF ADDRESS CHANGE
FOR YEAR ENDING
CHECK IF "FINAL RETURN" Date Operations ceased:__________(Required to close account.)
* ALL LICENSEES MUST ANSWER THE QUESTIONS BELOW *
A. Principle business activity:
B. During the past year did Federal Authorities change or propose to change net income reported for that year or any prior year?
If YES, which year(s) was adjusted?
(Attach statement of changes)
C. Principle owner/administrative officer:
D. Did you file a consolidated return?
(If yes, see instructions)
E. Was business activity discontinued?
or Sale / Transfer?
If sale / transfer state sucessor
name and address:
Did you make payments in the sum of $600.00 or more to any individual for services rendered in Pulaski County
other than an employee? IF YES, YOU ARE REQUIRED TO FILE COPIES OF FEDERAL FORM 1099.
* ALL LICENSEES MUST COMPLETE PAGE 2 OF THIS FORM BEFORE COMPLETING THIS SECTION *
21. Enter ADJUSTED NET PROFIT (From line 16 on the back of this form):
22. Enter percentage from Line 19 or 20
23. Net Profits Allocation (Line 21 X Line 22)
24. a) Pulaski County License Fee " for work performed in Pulaski County "
(Line 23 X 1%)
b) Pulaski County License Fee " for work performed in Somerset City "
(Line 23 X .8%)
25. Credits: Estimated Payments
26. Balance of License Fees Due (Line 24 minus Line 25)
27. Penalty - 5% per month, not to exceed 25% - Minimum $25
Penalty due on amount owed from original due date, unless appropriate estimated payments were made.
If payment not made by extension date, penalty will be calculated back to original due date
28. Interest - 12% per annum
Calculate interest on amount owed on Line 26 from original due date.
29. Total amount due
30. Underpayment Penalty (If line 29 is greater than $5,000 see instructions)
(refunds will only be given for more than $100.00. Otherwise your account will be credited toward future filings)
I hereby certify, under penalty of perjury, that the statements made herein and any supporting schedules are true, correct, and complete to the best of my knowledge.
Preparer Signature (Return must be signed.)
Taxpayer Signature (Return must be signed)
Social Security No.
If you have questions concerning this form visit or call (606)679-2393
Make check payable to: TAX ADMINISTRATOR
Mail this form along with supporting schedules to: TAX ADMINISTRATOR * P O BOX 658 * SOMERSET, KY 42502
This return must be filed and paid in full by the fifteenth day of the fourth month after the close of the fiscal/calendar year, unless an extension of time to file has been granted.