FORM 543

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

Occupational Reconciliation
for the Calendar Year

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The grey fields are calculated and do not need to be filled out.
If the amount of a field is 0, enter a 0.
Your total amount will appear once all possible fields have been filled out.

For the Calendar Year ending December 31, 20

Filer's Name* Employer's Name* Employer's Address*

City* State* Zip*

Quarterly Totals

As reported on Form 541Q.

	Gross Wages, Etc	Wages Allocable to Lebanon	License Fee Payable @ 1%	Amount Remitted to City of Lebanon
1rst
2nd
3rd
4th
Totals:

Employee List

(Use Continuation Sheet, Form 543C for additional employees or use W-2 Forms in lieu of 543C)

Total number of employees reporting:

	Employee SSN	Employee Name	Address of Employee	Gross Wages, Paid	Wages Allocable to Lebanon, KY	Occupational License Tax Withheld
Employee 1:	- -
Employee 2:	- -
Employee 3:	- -
Employee 4:	- -
Employee 5:	- -
Employee 6:	- -
Employee 7:	- -
Employee 8:	- -
Employee 9:	- -
Employee 10:	- -
Employee 11:	- -
Employee 12:	- -
Employee 13:	- -
Employee 14:	- -
Employee 15:	- -
Employee 16:	- -
Employee 17:	- -
Employee 18:	- -
Employee 19:	- -
Employee 20:	- -
Employee 21:	- -
Employee 22:	- -
Employee 23:	- -
Employee 24:	- -
Employee 25:	- -

Check the button below to acknowledge that you have filled out all required fields and understood the requirements and instructions given for Tax Form 543*