Commonwealth of Kentucky
Authorization to Submit Employees Annual
DEPARTMENT OF REVENUE
Wage and Tax Statements Via
Kentucky Department of Revenue Web Site
1. Check appropriate box:
Initial request for PIN (personal identification number).
Request to change PIN due to security issue, i.e., new employee responsible for submitting W-2 information or
PIN security has been compromised.
FEIN changed, new PIN required.
2. Name, address and federal employer identification number of person, organization or firm
requesting Web filing:
Business Name _____________________________________
Street Address ________________________________ City/State/ZIP _______________________________
3. Name, title and telephone number of contact person:
Contact Name ________________________________________
Phone Number _____________________
E-mail Address** __________________________________
4. Estimated number of wage and tax statements to be reported: ___________________________________
Signature of Person Completing Authorization
Please submit the request to:
Kentucky Department of Revenue
Withholding Tax Branch
P.O. Box 181, Station 57
Frankfort, KY 40602-0181
*If more than one FEIN is involved, please use the FEIN of the submitting/transmitting entity.
**This gives Kentucky Department of Revenue permission to confirm the status to the employer using the
confidential e-mail address provided on the form.
Please Note: It is important to get your system/network administrator involved immediately to ensure that you have
the proper capabilities. Kentucky Department of Revenue provides a secure Web site, but there are often limitations
in your system or network. Please work with your system/network administrator early to ensure your success!