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10A100-FI (3-07)

Page 2

CONTACT PERSON (Must be completed)

Name

Title

Daytime

E-mail Address (Optional)

Telephone

, Ext.

( By supplying your e-mail address, you grant the Department of Revenue

Fax

permission to contact you via the Internet.)

SECTION C

TELL US ABOUT YOUR BUSINESS OR ORGANIZATION (Must be completed)

Yes

Does your business or organization:

A Have employees or will you hire employees to work in Kentucky within the next 6 months?..................................................................

B Employ Kentucky residents who work outside the state of Kentucky on which you wish to

voluntarily withhold? ............................................................................................................................................................................................................

(An employee is anyone who works 24 days or more during a quarter OR earns more than $50 a quarter.

This includes family members who receive wages.)

If your business is a corporation or a limited liability company choosing taxation as a corporation for federal purposes,

do or will the Kentucky officers receive compensation other than dividends?...................................................................................................

If you answered "Yes" to EITHER question 24 or 25, or are adding an additional account, you must complete Section D.

Does or will your business or organization:

A Make retail sales in Kentucky?............................................................................................................................................................................................

B Make wholesale sales in Kentucky? ..................................................................................................................................................................................

Does or will your business or organization:

A Install repair or replacement parts in tangible personal property? (See instructions)...................................................................................

B Produce, fabricate, process, print or imprint tangible personal property? (See instructions).....................................................................

Does or will your business or organization rent or lease tangible personal property to others,

including related companies? (See instructions).............................................................................................................................................................

Does or will your business or organization charge taxable admissions? (See instructions)............................................................................

Does or will your business or organization rent temporary lodging to others? ..................................................................................................

Do or will you sell for or are you a manufacturer's agent who solicits orders for a nonresident

seller not registered in Kentucky? (See instructions).......................................................................................................................................................

Does or will your business or organization receive receipts from the breeding of a stallion to a mare in Kentucky?...........................

Does or will your business sell: (Check all that apply)

Coal ..........................................................................................................................................................................................................................................

Other minerals......................................................................................................................................................................................................................

Water utilities.........................................................................................................................................................................................................................

D Natural, artificial or mixed gas ........................................................................................................................................................................................

Electricity ................................................................................................................................................................................................................................

Communication services...................................................................................................................................................................................................

G Sewer services ......................................................................................................................................................................................................................

Yes

H Cable services ....................................................................................................................................

Satellite broadcast services ...........................................................................................................

If you answered "Yes" to ANY of questions 26 through 33 (except 33H or 33I), or are adding an additional account, you must

complete Section E AND you may SKIP questions 34-36.

Is your business or organization a construction company (contractor) that brings equipment

into Kentucky for use? ..............................................................................................................................................................................................................

Is your business or organization a construction company (contractor) that brings into this state

construction materials or supplies on which no Kentucky sales tax or equivalent has been paid? .............................................................

Does or will your business or organization make purchases from out-of-state vendors and not pay

Kentucky sales or use tax to the seller on those purchases? ......................................................................................................................................

f you are a professional service business, please see instructions for important additional details.

If you answered "Yes" to ANY of questions 34 through 36, you must complete Section F.

Is your business or organization a corporation, S corporation, limited partnership, limited liability partnership (LLP),

limited liability company (LLC), professional limited liability company (PLLC), association, homeowner's association, real estate

investment trust (REIT), regulated investment company (RIC), real estate mortgage investment conduit (REMIC), financial

asset securitization investment trust (FASIT) or similar entity created with limited liability for the partners, members

or shareholders? ..........................................................................................................................................................................................................................

If you answered "Yes" to question 37, you MUST answer questions 38 through 45. Sole Proprietorships and General

Partnerships may SKIP questions 38 through 45.