Please fill out all fields.
The grey fields are calculated for you 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.

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Filer Name (First and Last name)*

Business Name* Street Address* City* State* Zip*

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Enter either your Federal Tax ID or your Social Security Number

Calendar or Fiscal Year Ended*
Federal Tax ID or Social Security Number*
SSN

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1. Net Profits subject to License Fee (Entered from Line 7, Schedule A, Page 2)
2. City of Lebanon License Fee @ 1%
3. Interest @ 12% per annum
4. Penalty @ 5% per month or portion of month
5. Total (Items 2, 3, and 4)
6. Less Credits (Entered from Line 2, Schedule D, Page 2)
7. Balance Due

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1. Select Which: * Corporation Partnership Individual Owner Fidiciary Other 2. Nature of Business (Trade)* 3. Date Business was started or Trust was created*

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4. Did you pay a business privilege License for the Previous Year? *
Yes No 5. If Organization was discontinued, state whether by dissolution or sale* If by sale, enter the name and Address of Successor Organization

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6. Did you have any Employees in Lebanon during the taxable year?* Yes No 7. Has the lebanon License Fee been withheld from All Subject Employees and Remitted Quarterly in accordance with Regulations? Yes No If No, Explain:

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8. Has Return of Info. for each employee, as per the regulations been forwarded to the License Fee Division Yes No 9. Check whether this Return is prepared on Cash or Accrual Basis
Cash Accrual

10. Enter the Name and Address of each place of Business operated Subject to Lebanon License Fee and check if NOT included in this return

Business Name	Business Address	NOT Included

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Computation of Net Profits subject to License Fee

1. Net Income Per Federal Return (Form 1040, 1041, 1065, 1120)

2. Add Items not deductible under License Fee Ordinance (Schedule B)

3. Total (Line 1 and Line 2)

4. Deduct Item not subject under License Fee Ordinance (Schedule B)

5. Adjusted Income for Calendar year, or Fiscal Year Ending

6. Percent (As determined by Schedule C)

7. Net Profits subject to Lebanon License Fee (Enter as Item 1, Page 1)

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Adjustment of Net Profit for federal tax purposes to Provisions of Lebanon License Fee Ordinance

NOTE: Add and/rr Deduct only those items which are included in calculating Net Income per Federal Return.

Items NOT Deductible - ADD		Items NOT Subject - DEDUCT
A. State or Local Taxes based on Income		G. Interest on Corporate Bonds
B. License Fee under this Ordinance		H. Interest on U.S. Government Securities
C. Net Operating Loss Deduction		I. Royalties on Patents, Copyrights
D. Partners' Salaries (attach schedule)		J. Dividends
		K. Capital Loss
E. Other Items (list)		L. Other Items (list)
F. Total Additional (Enter as Line 2, Schedule A)		M. Total Deductions (Enter as Line 4, Schedule A)

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Business Allocation Percentage Formula
Divide (A) by (B) to obtain a decimal. Carry out the decimal ATLEAST 6 places.

Allocation Factors	Column 1 Lebanon Factor (A)	Column 2 Total Factor (B)	Column 3 Percentage
1. Gross Sales of Merchandies, Less Returns and Allowance (Do Not include Discounts Allowed)
Charges for Work or Services Performed
Other Income
Total Business Reciepts Factor
2. Wages, Salaries, and Other Personal Service Compensation
Total Net Wages Factor
3. Total Percents
4. Average Percentage (Carry Percentage in Col 3 to Line 6, Schedule A)

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Credits

1. Amount Minimum License Fee Paid for Taxable Year License #
2. Estimates & Extension Payment(s)
3. Total Credit (Enter as Item 6, Page 1)

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Total Amount Due:

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