Form 10a100 - Kentucky Tax Registration Application Page 4
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410A100 (4-09)
Page 4
SECTION H
COAL SEVERANCE/PROCESSING TAX ACCOUNT AND/OR COAL SELLER/PURCHASER CERTIFICATE ID #
Must be completed if you answered “YES” to EITHER question 44 or 45.
Coal Brokers who do not mine or process coal are not required to complete questions 71 through 79.
70. Date mining/processing or coal brokering began or will begin
71. Coal Severance & Processing Tax returns should be mailed to:
/
/
(mm/dd/yyyy)
Use the same address as listed on Page 1, Section B, Item 7
c/o or Attn.
72. County
Address
(_______) _______ – _________________
73. Mailing Telephone No.
LIST THE MINE LOCATIONS THAT YOU OPERATE IN KENTUCKY:
City, State, Zip Code
74. Mine Name
75. Mine Location (County)
76. Contract Miner Name (If Applicable)
77. Surface Disturbance Mining Permit Number (If Available)
Yes
No
78. Do you operate additional mine locations?
If yes, attach a continuation page listing the information requested in questions 74 through 77 for each mine location.
79. Physical location address where business records are kept:
Use the same address as listed on Page 1, Section B, Item 7
c/o or Attn.
Address
City, State, Zip Code
IMPORTANT: THIS APPLICATION MUST BE SIGNED BELOW:
The statements contained in this application and any accompanying schedules are hereby certifi ed to be correct to the best knowledge and
belief of the undersigned who is duly authorized to sign the application.
Signed:
Signed:
Title:
Title:
/
/
/
/
Date:
(mm/dd/yyyy)
Date:
(mm/dd/yyyy)
For assistance in completing the application, please call the Taxpayer Registration Section at (502) 564-3306, Monday through Friday between the
hours of 8:00 a.m. and 5:00 p.m., Eastern time, or you may contact one of the Kentucky Taxpayer Service Centers or use the Telecommunications
Device for the Deaf. Each offi ce is open Monday through Friday, 8:00 a.m. to 5:00 p.m., local time. For a list of Taxpayer Service Centers and
phone numbers, see the Instructions.
MAIL completed application to:
KENTUCKY DEPARTMENT OF REVENUE
PO BOX 299, STATION 20
FRANKFORT, KENTUCKY 40602-0299
or
FAX to:
(502) 227-0772
If you are applying for a withholding account and/or a sales and use tax account and would like to receive a packet to register for
Electronic Funds Transfer (EFT), please call (502) 564-6020.
This form does not include registration for cigarette tax, minerals or natural gas severance tax, motor fuels tax, utility gross receipts
license tax, telecommunications tax or any other miscellaneous taxes administered by the Department of Revenue. Please visit
our Web site at for registration information for these taxes.
This form does not include registration for Unemployment Insurance or Workers’ Compensation Insurance. Please contact the Business
Information Clearinghouse toll free at (800) 626-2250 (outside Kentucky) or (502) 564-4252 (in Kentucky) to obtain information on these accounts
or contact the offi ces directly at the numbers below.
Unemployment Insurance
(502) 564-2272
Workers’ Compensation
(502) 564-5550
Secretary of State
(502) 564-2848
IRS—FEIN
(800) 829-4933
The Kentucky Department of Revenue does not discriminate on the basis of race,
color, national origin, sex, religion, age or disability in employment or the provision of
services.
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