Form 10a100 - Kentucky Tax Registration Application Page 3

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10A100 (2-05)
Page 3
FOR OFFICE USE ONLY
WH
SU
USE
CP
SECTION D
EMPLOYER’S WITHHOLDING ACCOUNT
(Must be completed if you answered “Yes” to question 24 OR 25, or you are registering for an additional account.)
47
Number of Employees in Kentucky:
______________________
48
Date Wages First Paid:
__ __ / __ __ / __ __ __ __
49
Estimated Quarterly Withholding in Kentucky:
$ _____________________
50
Send Mail Related to This Account to:
Same address as in Page 1, Section B, Item 7
Mailing Address ATTN: ________________________________
Street _______________________________
_______________________________
City
_______________________________
51
County _________________________________________
State, ZIP Code _______________________
52
Mail Address Telephone ( ______ ) ______ – __________
SECTION E
SALES AND USE TAX ACCOUNT
(Must be completed if you answered “Yes” to ANY of questions 26 through 32 (except 32H), or you are registering for an additional account.)
53
Date Sales Began or Will Begin:
__ __ / __ __ / __ __ __ __
54
Accounting Method:
Cash
Accrual
55
For multiple locations, do you wish to:
File Separately
File Consolidated
56
Do you sell new tires for motor vehicles?
Yes
No
57
Estimated Gross Monthly Sales:
$ _____________________
58
Send Mail Related to This Account to:
Same address as in Page 1, Section B, Item 7
Same address as in Section D, above
Mailing Address ATTN: ________________________________
Street _______________________________
_______________________________
City
_______________________________
State, ZIP Code _______________________
59
County _________________________________________
60
Mail Address Telephone ( ______ ) ______ – __________
SECTION F
CONSUMER’S USE TAX ACCOUNT
(Must be completed if you answered “Yes” to ANY of questions 33 through 35.)
61
Date Purchases Began or Will Begin:
__ __ / __ __ / __ __ __ __
(If you make a one-time purchase only, see instructions.)
62
Send Mail Related to This Account to:
Same address as in Page 1, Section B, Item 7
Same address as in Section D, above
Mailing Address ATTN: ________________________________
Street _______________________________
_______________________________
City
_______________________________
63
County _________________________________________
State, ZIP Code _______________________
64
Mail Address Telephone ( ______ ) ______ – __________
SECTION G
CORPORATION INCOME AND/OR LICENSE TAX ACCOUNT
(Must be completed if you answered “Yes” to ANY of questions 36 through 45.)
65
Date of Incorporation or Organization:
__ __ / __ __ / __ __ __ __
66
State of Incorporation or Organization:
______________________
67
Date of Qualification in Kentucky:
__ __ / __ __ / __ __ __ __
68
Is this corporation a member of an affiliated corporate group?
Yes
The legal corporate name is: _____________________________________________
DBA ________________________________________________________________
Address ______________________________________________________________
City, State, ZIP Code ___________________________________________________
FEIN __ __ – __ __ __ __ __ __ __
Start Date __ __ / __ __
No
69
Send Mail Related to This Account to:
Same address as in Page 1, Section B, Item 7
Same address as in Section D, above
Mailing Address ATTN: ________________________________
Street _______________________________
_____________________________________
City
_______________________________
70
County _________________________________________
State, ZIP Code _______________________
71
Mail Address Telephone ( ______ ) ______ – __________

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