PLEASE RETURN COMPLETED COPIES OF THIS FORM WITH PAYMENT
EMPLOYERS PAYROLL TAX RETURN					140 West Electric Ave.
FLEMINGSBURG OCCUPATIONAL					P.O. Box 406
LICENSE FEE					Flemingsburg, KY 41041
					Phone: (606) 845-5951
					Fax: (606) 845-0712
Name:						Filing Status
Federal ID:
DBA:					Monthly		Quarterly		Yearly
PLEASE INDICATE AT RIGHT THE FILING					Monthly Period Ended:
STATUS AND WITHHOLDING PERIOD
					Quarterly Period Ended:
Computer program will not update your account
without this information					Yearly Period Ended:
All organizations are required to submit 1% from gross wages paid employees for service within the City of Flemingsburg.
If the Flemingsburg payroll tax due is under $100 per month, your filing status is "quarterly".  For quarterly filers, payment
and this return are due on the last day of the month following the end of a quarter which is a period of three calendar months
ended on March 31, June 30, September 30, and December 31.  If Flemingsburg payroll tax due is over $100 per month,
your filing status is "monthly".  As a monthly filer, payment and this return are due by the fifteenth day following the end of the
first and second month of each quarter; the third month of each quarter, payment and this return are due by the last day of
the following month.
To change "Filing Status" from a monthly to a quarterly payroll tax filer or from a quarterly to a monthly filer, a written
request must be made to the License Fee Administrator.  Change of filing status cannot be made until request is approved.
				INSTRUCTIONS
Line 1:  enter total compensation paid during this quarter/month regardless of when or where earned.
Line 2:  enter the amount included in line 1 which represents payment for services performed or work done outside
Flemingsburg.  The employer must maintain adequate records to substantiate this amount.
Line 5:  A penalty of 10% is imposed after the due date of the return during which the license fee remains unpaid.
Line 6:  Interest accrues at a rate of 1% on unpaid license fees from the due date of the return until paid.
				WORKSHEET
1.  Total salaries, wages, commissions, and other compensation………………………….
2.  Amount included in line 1 paid for services outside Flemingsburg………………………
3.  Compensation subject to Flemingsburg Payroll Tax (line 1 minus line 2)……………..
4.  Flemingsburg Payroll Tax Due (1% of line 3)……………………………………………..
5.  Penalty (see instructions)……………………………………………………………………
6.  Interest (see instructions)……………………………………………………………………
7.  Total amount due (sum of lines 4,5, and 6)……………………………………………….
Make Check Payable to:  City of Flemingsburg
I hereby certify that the statements herein and in any copies of supporting documents are true, correct and complete
subject to any and all applicable fines and penalties.
	Signature			Title			Date