BUSINESS LICENSE

140 West Electric Ave.

STATUS CHANGE FORM

P.O. Box 406

Flemingsburg, KY 41041

Phone:  (606) 845-5951

Fax:  (606) 845-0712

If any of the following is applicable to your

Federal I.D.:

organization, please check the appropriate

DBA:

box below, complete the information

Street Address:

requested, sign this form, and return to the

City, State, Zip:

attention of the License Fee Administrator.

DO NOT ANTICIPATE WORKING IN FLEMINGSBURG

As a business location located outside of Flemingsburg, I do not anticipate working in Flemingsburg.

If I do get a job, I will notify the License Fee Administrator in order to activate my account.  A

Business License should be purchased before start of work.  (A business located within the City of

Flemingsburg must purchase a Business License whether working in Flemingsburg or not.)

I understand I am responsible for filing the Net Profits License Fee Return by April 15, or within 105

days from the end of my fiscal period.

NO LONGER IN BUSINESS

I am no longer in business.  Please enter the date you went out of business on the line below:

________________.  I understand even though I am no longer in business I am still required to file

the Net Profits License Fee Return for the period I was in business.  (This return is due by April 15, or

105 days from the end of your fiscal period.)  Please enter your forwarding address and phone number

below and be sure to sign this letter:

If business was sold or transferred please list name, address, and phone number of successor

and attach to this form.

CHANGE IN OWNERSHIP/LEGAL STRUCTURE

If the legal structure of your business changes by merger, by a change in form of ownership, or by

a change in Federal ID number (for example, a Sole Proprietor to an S-Corporation or to a

Corporation) written notice of such change is required or this completed form may be submitted.

The new owner must complete a new Business Application (Form 551), obtain a new City of

Flemingsburg account number, and purchase a new Business License.  Please contact the License

Fee Administrator.  Failure to purchase the Business License within thirty days of the change will

result in an additional $25.00 penalty.

CHANGE IN BUSINESS NAME, MAILING ADDRESS BUSINESS LOCATION, OR PHONE NUMBER

New business name:

New business location:

New mailing address:

New phone number:

If your Federal ID Number changed, please contact the License Fee Administrator.  A "CHANGE IN OWNERSHIP/

LEGAL STRUCTURE" requires completion of a Business Application (Form 551), a new City of Flemingsburg account

number, and purchase of a new Business License.

Signature

Title

Date