Form 1206 - Annual Reconciliation Form For 2016
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1Boone County Fiscal Court
2950 Washington Street
PO Box 960
Burlington, KY 41005
Annual Reconciliation Form for 2016
Name:
Acct #:_____________________
dba:
FEIN/SSN:__________________
Address:
Due Date: February 28, 2017
You must attach copies of W-2
City, State, Zip:
Forms or supporting documents
Boone County Board of Education Tax Withheld
Wages
Tax Withheld/Paid
# employees _________
st
1
Quarter
$______________
$______________
nd
2
Quarter
$______________
$______________
rd
3
Quarter
$______________
$______________
th
4
Quarter
$______________
$______________
TOTALS
$_______________
$______________
Total W-2 Wages Subject To This Tax per W-2’s $______________________ X .005 = $___________________
A. Difference between Quarterlies Remitted and W-2 Totals $__________________
Boone County Ordinance Tax Withheld
Wages
Tax Withheld/Paid
# employees _________
st
1
Quarter
$______________
$______________
nd
2
Quarter
$______________
$______________
rd
3
Quarter
$______________
$______________
th
4
Quarter
$______________
$______________
TOTALS
$______________
$______________
Total W-2 Wages Subject To This Tax per W-2’s $___________________ X .008 = $______________________
B.
Difference between Quarterlies Remitted and W-2 Totals $ ________________
Boone County Mental Health Tax Withheld
Wages
Tax Withheld/Paid
# employees:_________
st
1
Quarter
$______________
$______________
nd
2
Quarter
$______________
$______________
rd
3
Quarter
$______________
$______________
th
4
Quarter
$______________
$______________
TOTALS
$______________
$______________
Total W-2 Wages Subject To This Tax per W-2’s$___________________ X .0015 = $_____________________
C. Difference between Quarterlies Remitted and W-2 Totals $ ________________
# W-2’s attached
Summary: (A) + (B) + (C) _________________________
If difference is less than $5.00, nothing is to be paid or will be refunded. If greater than $5.00, please issue payment as
appropriate to avoid applicable penalties. If a refund is due, you must amend the appropriate quarterly return to obtain a
refund.
Signature:
Date:
Telephone # :
E-MAIL:
Form 1206
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