20__ Reconciliation				140 West Electric Ave.
		of Payroll Tax Withheld				P.O. Box 406
						Flemingsburg, KY 41041
						Phone:  (606) 845-5951
						Fax:  (606) 845-0712
	Enter average annual number of employees:
	Federal I.D.:
	DBA:
	Street Address:
	City, State, Zip:
			Total Payroll		Subject Payroll			License Fee Due
1	January	1		1		X 1.00% =	1
2	February	2		2		X 1.00% =	2
3	March or 1st Qtr	3		3		X 1.00% =	3
4	April	4		4		X 1.00% =	4
5	May	5		5		X 1.00% =	5
6	June or 2nd Qtr	6		6		X 1.00% =	6
7	July	7		7		X 1.00% =	7
8	August	8		8		X 1.00% =	8
9	September or 3rd Qtr	9		9		X 1.00% =	9
10	October	10		10		X 1.00% =	10
11	November	11		11		X 1.00% =	11
12	December or 4th Qtr	12		12		X 1.00% =	12
13	Total Year	13		13		X 1.00% =	13
14	Actual License Fee withheld per W-2s						14
15	Enter the larger of line 13 or 14						15
16	Actual License Fee remitted for the year						16
17	Difference between lines 15 and 16 (if any, check applicable box below)						17
	Minor difference attributable to fractional variations only (no adjustments due).
	Difference indicates insufficient total remittance for year.  Check in payment attached.
	Difference indicates overpayment not attributable to fractional variations.  Full
	explanation and claim for refund is attached.
	Signature				Title			Date