Form K-4fc-42a807 - Fort Campbell Exemption Certificate

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Form K-4FC
FORT CAMPBELL EXEMPTION CERTIFICATE
42A807 (10-98)
(For use by Fort Campbell, Kentucky, employee
Commonwealth of Kentucky
who is not a resident of Kentucky)
Date Revoked _________________
REVENUE CABINET
_______________________________________________________________________________________________________________
Type or Print Full Name
Social Security Number
Effective Date (MM/DD/YY)
_______________________________________________________________________________________________________________
Home Address (Must be completed, physical location required)
City, State and ZIP Code
_______________________________________________________________________________________________________________
Mailing Address if different
City, State and ZIP Code
Employee’s Certification—I certify under the penalties of perjury that I am a resident of _______________________________
State
and that I do not maintain a residence in Kentucky. I understand the exemption applies only to wages earned as an
employee at Fort Campbell, Kentucky. This certficate must be revoked 10 days after a move or change of address to
Kentucky.
Signature ________________________________________
Date _______________________
Form K-4FC
42A807 (10-98)
FORT CAMPBELL EXEMPTION CERTIFICATE
Commonwealth of Kentucky
(For use by Fort Campbell, Kentucky, employee
REVENUE CABINET
who is not a resident of Kentucky)
Date Revoked _________________
_______________________________________________________________________________________________________________
Type or Print Full Name
Social Security Number
Effective Date (MM/DD/YY)
_______________________________________________________________________________________________________________
Home Address (Must be completed, physical location required)
City, State and ZIP Code
_______________________________________________________________________________________________________________
Mailing Address if different
City, State and ZIP Code
Employee’s Certification—I certify under the penalties of perjury that I am a resident of _______________________________
State
and that I do not maintain a residence in Kentucky. I understand the exemption applies only to wages earned as an
employee at Fort Campbell, Kentucky. This certficate must be revoked 10 days after a move or change of address to
Kentucky.
Signature ________________________________________
Date _______________________

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