Date_____________Signed __________________________
$ ______________
$ ______________
EMPLOYER'S RETURN OF LICENSE FEE WITHHELD*If no wages were paid this period, mark "NONE" and return this form.
Total salaries, wages,commissions and othercompensation paid to allemployees for services withinHarrison County.
$ ______________
Licensee Account Number
Tax Due at - $ ______________Adjustment for preceding quarters(past due balances/underpayments)
Interest (12% per year) -
Balance Due
Overpayment to be credited to nextquarter $ ______________
I hereby certify that the information, schedules, statements and exhibits filedherewith, are true and correct.
Official Title ___________________________________________
HARRISON COUNTY TAX ADMINISTRATOR
Phone Number
FOR PERIOD ENDING
Month Day Year
Make checks payableand mail to:
HARRISON COUNTYTAX ADMINISTRATOR
CYNTHIANA KY 41031
RETURN DUE ON OR BEFORE:Month Day Year
Federal ID No.
*PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS.Indicate any name or address changes above. HCOTF-Rev.10/23/08
Phone Number
(859) 234-7136
111 S. MAIN ST.,P.O. BOX 708
1.
2.
3.
4.
5.
7.
6.
$ ______________
Penalty (5% per month,maximum not to exceed 25%,minimum $25) -
$ ______________
1.5%
