Form 10a104 - Update Or Cancellation Of Kentucky Tax Account(S) Page 3
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410A104 (6-11)
Page 3
15.-16. OWNERSHIP DISCLOSURE—RESPONSIBLE PARTY UPDATE
Provide updated information for existing responsible parties or add additional responsible parties.
Full Legal Name (Last, First, Middle)
Full Legal Name (Last, First, Middle)
Residence Address
Residence Address
City
State
Zip Code
City
State
Zip Code
Social Security Number (REQUIRED)
Social Security Number (REQUIRED)
Telephone Number
Telephone Number
(
)
–
(
)
–
Business Title
Effective Date of Title
Business Title
Effective Date of Title
/
/
/
/
Does this new Responsible Party replace a previous one?
Does this new Responsible Party replace a previous one?
Yes
No
Yes
No
If yes, list the name of the previous Responsible Party and their end date.
If yes, list the name of the previous Responsible Party and their end date.
SECTION F
UPDATES TO MAILING ADDRESS AND PHONE NUMBERS FOR TAX ACCOUNTS
17. Start Date for Address Change
19. List New Mailing Address
/
/
c/o or Attn.
18. Tax Accounts for which the Address Change Applies
Address
(Check all that apply)
Employer’s Withholding Tax
Consumer’s Use Tax
Sales and Use Tax
Corporation Income Tax
City
State
Zip Code
(including Transient Room
and/or Limited Liability
and/or Motor Vehicle Tire
Entity Tax
County (if in Kentucky)
Mailing Telephone Number
Fee Accounts)
(
)
–
Coal Severance and
Processing Tax
Note: To change the address or phone number for Telecommunications Tax or Utility Gross Receipts License Tax, you must use the online system.
20. Start Date for Address Change
22. List New Mailing Address
/
/
c/o or Attn.
21. Tax Accounts for which the Address Change Applies
Address
(Check all that apply)
Employer’s Withholding Tax
Consumer’s Use Tax
Sales and Use Tax
Corporation Income Tax
City
State
Zip Code
(including Transient Room
and/or Limited Liability
and/or Motor Vehicle Tire
Entity Tax
County (if in Kentucky)
Mailing Telephone Number
Fee Accounts)
(
)
–
Coal Severance and
Processing Tax
Note: To change the address or phone number for Telecommunications Tax or Utility Gross Receipts License Tax, you must use the online system.
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