FORM 541Q

City of Lebanon, Kentucky
240 West Main Street/P.O. Box 840
Lebanon, Kentucky 40033

Employer's Quarterly Return:
Occupational License Fee Withheld

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Filer Name (First and Last name)*

1. Total salaries, wages, commissions, and other compensation paid employees this quarter*
2. Amount included in line 1 which was paid for services outside of Lebanon*
3. Compensation subject to Lebanon license fee (Line 1 less Line 2)*

4. Lebanon license fee payable (1% of line 3)*

5. Monthly Payments made (from item 11)*

6. Balance due with this return (line 4 less line 5)*

7. Penalty (see instruction - line 7)*

o 8. Interest (12% per annum)*

9. Total amount due (sum of lines 6, 7, and 8)*

10. Total No. of employees subject to Lebanon license fee this quarter: *

Summary of Monthly Payments

Date and Amount of Payment 1

Date and Amount of Payment 2

Date and Amount of Payment 3

Date and Amount of Payment 4

Date and Amount of Payment 5

Date and Amount of Payment 6

Monthly Payments Total

Employer Information

Employer's Name* Employer's Address* Tax ID*

Date Signed: *

Title *

Return for Quarter Ended *

Check the button below to acknowledge that you have filled out all required fields and understood the requirements and instructions given for Tax Form 541Q*

Total Amount Due:

Instructions

The return is for a period of three calendar months ended March 31, June 30, or December 31 and is due on, or before the last day of the month, following the end of the quarter. More detailed information for employers may be obtained from the Tax Administrator, City of Lebanon, P.O. Box 840, Lebanon, KY 40033

Line 1: Enter total compensation paid during the quarter, 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 Lebanon. The employer must maintain adequate records to substantiate this amount.

Line 5: See instructions on Form 501 for monthly payment requirement. Summarize monthly payments (if required) made this quarter in item 11: transfer total to line 5

Line 7: A penalty of 5% is imposed for each month or fraction thereof after the due date of the return during which the license fee remains unpaid

Line 8: Interest accrues on unpaid license fees at a rate of 12% per annum from the due date of the return until paid

FORM 541Q

City of Lebanon, Kentucky 240 West Main Street/P.O. Box 840 Lebanon, Kentucky 40033

Employer's Quarterly Return: Occupational License Fee Withheld