Application For Occupational License Tax Amnesty Form - Louisville Metro Revenue Commission
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1LOUISVILLE METRO REVENUE COMMISSION
APPLICATION FOR OCCUPATIONAL LICENSE TAX AMNESTY
Deadline for filing is May 31, 2005. Review instructions prior to completing this application.
INSTRUCTIONS
1. Please read the Amnesty FAQ’s to determine which Occupational License Taxes are eligible and to determine whether you qualify.
2. Complete all information requested in the application and sign it. Incomplete applications are cause for denial of Amnesty eligibility.
3. FULL PAYMENT MUST accompany application to be eligible for the Amnesty Program. Applications without payment will be
denied.
4. By participating in the Amnesty Program, ALL penalties and interest will be waived on delinquent Occupational License Taxes remitted.
5. Applicant certifies that amounts listed represent unpaid Occupational License Tax liabilities for periods ending on or before 12/31/2003.
6. For Amnesty periods, you agree to waive your rights to contest the license fees reported and to future claims for refund or credit.
7. Attach all W1 (Employee Withholding) or OL (Net Profit) Returns, plus all supporting federal schedules to application.
Existing Accounts -Enter Your Metro Revenue Commission Account Number______________________
Check account type applicable to your business: (Check here
if an LLP or LLC and check appropriate box for individual, partnership, or corporation.
)
Individual
Partnership
Corporation
S-Corporation
8. Legal name of the Individual, Partnership, or Corporation____________________________________________________________
9. Trade Name or DBA, if any____________________________________________________________________________________
10. Enter your Louisville Metro Business Address (No P.O. Box)
11. Enter Applicant’s Address (No P.O. Box)
Street Address:
Street Address:
City, State, and Zip Code (Provide 9 digits, if available):
City, State, and Zip Code (Provide 9 digits, if available):
Day Phone: (
)
Fax Number: (
)
Day Phone: (
)
Fax Number: (
)
12. Type of work you are performing or the business activity being conducted______________________________________________
13. For an individual account, enter your Social Security Number._____________ -_____________-__________________
14. For corporations, partnerships, or individuals with employees, enter your Federal Tax ID Number._______-___________________
15. If your business has ceased operating in Louisville Metro, please indicate stop date._______/_______/___________
INDICATE PERIODS FOR WHICH LICENSE TAX IS DUE.
Return Type (Check One)
License Tax Type
Original
Amended
Payment
(OL) Net
(W-1)Wage
Period
Period
Amount Due
Return
Return
Only
Profit
Withholding
Beginning
Ending
$
/
/
/
/
$
/
/
/
/
$
/
/
/
/
$
/
/
/
/
$
/
/
/
/
$
/
/
/
/
$
/
/
/
/
$
TOTAL AMOUNT DUE
Metro Revenue Commission
Make Check / Money Order Payable To "
"
Title
Date
__________________________________________________________________
:______________________________________
:________________________
Applicant/Licensee Printed Name
Contact Phone Number
___________________
__________________________________________________________________
: (
)
Applicant/Licensee Signature
MAILING ADDRESS: P.O. BOX 34500 • LOUISVILLE, KENTUCKY 40232-4500
Telephone: (502) 574-4693 • •
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