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8879(C)-K

41A720-S8 (10-13)

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

PART III - Declaration of Authorized Representative of Entity (Sign only after Parts I and II are completed.)

30. 

I authorize the Kentucky Department of Revenue and its designated Financial Agent to initiate an ACH electronic funds withdrawal entry to the

financial institution account indicated above for payment of the state taxes owed on this return. I also authorize the financial institutions involved

in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to

the payment.

If this is a balance due return, I understand that if the Department of Revenue does not receive the full and timely payment of the tax liability, the entity

will remain liable for the tax liability and all applicable interest and penalties.

I, the undersigned, declare under the penalties of perjury, that I am an officer of the above corporation, partner or member of the above limited liability

pass-through entity, or partner of the above general partnership and that I have examined a copy of the corporation’s, limited liability pass-through

entity’s, or general partnership’s electronic tax return, including accompanying schedules and statements, and to the best of my knowledge and belief,

it is true correct and complete. I further declare that the amounts in Part I above are the amounts shown on the copy of the Form 720, 720S, 725, 765 or

765-GP electronic tax return.

Signature of Authorized Representative __________________________________________________________________

Date ________________________________

Type or Print the Name and Title

of the Authorized Representative Signing this Document __________________________________________________________________________________________

PART IV - Declaration and Signature of Electronic Return Originator (ERO) and Paid Preparer

I, the undersigned, declare that I have reviewed the above tax return and that the entries on Part I above are correct and complete. If I am only the ERO, I am

not responsible for reviewing the tax return and only declare that this tax return accurately reflects the data on the tax return. The corporate officer of the

above corporation, partner or member of the above limited liability pass-through entity, or partner of the above general partnership will have signed this

form before I submit the tax return. I will give the corporate officer of the above corporation, partner or member of the above limited liability pass-through

entity, or partner of the above general partnership all forms, including accompanying schedules and statements, filed with the Kentucky Department of

Revenue. If I am also the paid preparer, I declare under the penalties of perjury that I have examined this tax return, including all accompanying schedules

and statements, and to the best of my knowledge and belief, it is true, correct and complete.

Check ¨ if also a paid preparer.

Check ¨ if self-employed.

ERO’s signature ______________________________________ Date _________________________ I.D. Number of ERO ____________________________________

Firm’s name (or your

name if self-employed) ________________________________________________________________ FEIN __________________________________________________

Address ______________________________________________________________________________ ZIP Code ______________________________________________

I, the undersigned, declare under the penalties of perjury that I have examined this tax return, including all accompanying schedules and statements, and

to the best of my knowledge and belief, it is true, correct and complete.

Preparer’s signature __________________________________ Date _________________________ I.D. Number of Preparer ________________________________

Firm’s name (or your

name if self-employed) ________________________________________________________________ FEIN __________________________________________________

Address ______________________________________________________________________________ ZIP Code ______________________________________________