Form Ol-3e - Extension Request And/or Estimated Payment

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EXTENSION REQUEST AND/OR ESTIMATED PAYMENT FORM OL-3E

PHONE: (502) 574-4860

FAX: (502) 574-4818

Application Must be Submitted by the 15th Day of the 4th Month Following the Close of Tax Year

FOR YEAR ENDING

MONTH

YEAR

DAY

Name &

ACCOUNT

Address

NUMBER

PLEASE WRITE YOUR ACCOUNT # ON YOUR CHECK.

INDIVIDUAL SOCIAL SECURITY NUMBER __________________________________________

FEDERAL ID NO. (CORP. OR PARTNERSHIP) _______________________________________

(Each individual taxpayer or business entity registered with this agency for the purpose of reporting local occupational taxes

must apply separately to this agency for an extension of time within which to file their local tax return.)

NOTICE-CORPORATIONS AND PARTNERSHIPS

If this extension request is for a tax period of less than 12 months, please indicate the reason.

[

]

Change in tax year to end on______/______/______ .

[

]

Final return -- Business Ceased ______/______/______ .

[

]

Corporate Merger --

Short year return due to merger on ______/______/______ with:

Name and address

Federal ID

After this short year return, our tax year will end on ______/______/______ .

[

]

Corporate Acquisition --

Short year return due to the acquisition on ______/______/______ by:

Name and address

Federal ID

After this short year return, our tax year will end on ______/______/______ .

[

]

Other (please explain)

INTEREST AND PENALTIES - 12% interest is charged from the regular due date of the return until the tax due is fully paid. Additionally, unless estimated

payments equal to at least 90% of the final tax liability are made by the regular due date of the return, a late payment penalty of 1% per month (to a maximum

of 5% cumulative) of the unpaid amount as finally determined will be assessed.

MAKE ALL CHECKS PAYABLE AND MAIL TO: Louisville/Jefferson County Metro Revenue Commission, P.O. Box 35410, Louisville, KY 40232-5410

*My signature on the extension request shall serve as certification that the taxpayer is subject to file a tax return for the tax year recorded above. I

understand that this extension request may be used as evidence that the taxpayer was subject to file an occupational license return for the period referenced.

An estimated payment of $ _____________________________________ is enclosed.

Signature of Party Requesting

Print Name

Phone Number

ATTENTION - Taxpayers who may have a total tax obligation above $5,000 in any tax year may be required to submit quarterly estimated

payments. This obligation includes taxes for the City of Louisville, Jefferson County, TARC and the School Boards.

SEE REVERSE SIDE OF THIS PAGE FOR DETAILS

Revised 02/04/2003