Form 10a100 - Kentucky Tax Registration Application

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KENTUCKY
10A100 (4-09)
FOR OFFICE USE ONLY
TAX REGISTRATION
Commonwealth of Kentucky
CRIS
Coded
DEPARTMENT OF REVENUE
APPLICATION
•
Incomplete or illegible applications will delay processing
CASE#
Date Coded
and will be returned.
•
Print or type the application using blue or black ink only.
Entity ID
Data Entry
•
Please see instructions for questions regarding completion
of the application.
•
NAICS
SIC
Date Data Entered
Need Help? Call (502) 564-3306 or visit
SECTION A
REASON FOR COMPLETING THIS APPLICATION (Must Be Completed)
/
/
1. Effective Date
2. Previous Account Numbers (If Applicable):
Opened new business
Kentucky Withholding Tax
Resumption of business
Kentucky Corporation Income Tax
Opened new location of current business (See Instructions)
Kentucky Limited Liability Entity Tax
Applying for additional tax accounts
Kentucky Sales and Use Tax
Hired employees working in Kentucky
Kentucky Coal Severance Tax
Hired employees working out-of-state with a KY residence
Federal ID Number (FEIN)
3. Current Account Numbers (If Applicable)
Updating information (See Instructions)
State Government Vendor and/or Affi liates
Kentucky Withholding Tax
Other (Specify)
Kentucky Corporation Income Tax
Kentucky Limited Liability Entity Tax
Change in Ownership
Kentucky Sales and Use Tax
Ownership change–Previous type
Kentucky Coal Severance Tax
Purchased an existing business (See Instructions)
Federal ID Number (FEIN)
SECTION B
BUSINESS / RESPONSIBLE PARTY / CONTACT INFORMATION (Must Be Completed)
4. Legal Business Name
5. Doing Business As (See Instructions)
6. Federal Employer Identifi cation Number (FEIN)
—
7. Business Location–Street Address (DO NOT List a PO Box as a Location Address)
City
State
Zip Code
8. County (if in Kentucky)
9. Location Telephone
(_______) _______ – ______________________
10. A. Describe the nature of your business activity in Kentucky, including any services provided.
B. Describe the nature of your business activity outside Kentucky, including any services provided.
C. If you make sales in Kentucky, list the products sold.
11. Accounting Period
Calendar Year (year ending December 31
st
)
Fiscal Year (year ending
/
(mm/dd))
12. Ownership Type
Cooperative
Sole Proprietorship
Association
Real Estate Investment Trust
General Partnership
Homeowner’s Association
Estate
Other (See Instructions)
Corporation
Joint Venture
Limited Partnership
S corporation
Trust
Limited Liability Partnership (LLP or LLLP)
Government
Non-Profi t (See Instructions)
Limited Liability Company (LLC)
13. If “LIMITED LIABILITY COMPANY” is Checked Above, How Will You be Taxed for Federal Purposes?
Single Member-Disregarded Entity, member taxed as:
A. Partnership
C. S Corporation
E. Individual
B. Corporation
D. Non-Profi t
F. Other (Specify)
14–17. OWNERSHIP DISCLOSURE–RESPONSIBLE PARTIES (REQUIRED FOR ALL OWNERSHIP TYPES)
Social Security Number
Name (Last, First, MI)
Business Title
Residential Address, City, State, Zip Code
(REQUIRED)
18. Contact’s Name
19. Contact’s Title
20. Contact’s E-Mail Address
(By supplying your e-mail address you grant the Department of Revenue permission to contact you via the Internet.)
(_______) _______ – _______________
_______________
Fax (_______) _______ – _______________
21. Daytime Telephone
Extension

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