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Reconciliation of Eminence Occupational License Fee Withheld

During Year Ending 20____
To Be Filed With the 4th Quarter's Return By January 31 of with the FINAL
Quarterly Return Of The Closing of Any Business Either By Sale of Dissolution

TYPE OR PRINT IN THIS SPACE EMPLOYER'S NAME AND
ADDRESS OF PRINCIPAL PLACE OF BUSINESS		 1.  Total number employees as listed hereon _______
_________________________________________ 2.  Total Eminence License Fee Withheld _______
_________________________________________ Quarter ended Mar. 31, ______ _______________
_________________________________________ Quarter ended June 30, ______ _______________
_________________________________________ Quarter ended Sept. 30, ______ _______________
Quarter ended Dec. 31, ______ _______________

Total remitted for year

 _______________
Social Security # Name and Address of Employee Gross Wages Paid Occupational License Withheld
IF OTHER PAGES USED TOTAL THIS PAGE $ $
If report is completed on this page total here $ $

This document is available from the city of Eminence web site.
http://www.eminencekentucky.com
Provided for information purposes only.
Specific questions should be
directed to the City Clerk's office.
Internet Posted on 3/26/02

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