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2012

740NP-WH

*1200010292*

Taxable Year Ending

40A201 (10-12)

__ __ / __ __

Commonwealth of Kentucky

Mo.

Yr.

DEPARTMENT OF REVENUE

KENTUCKY NONRESIDENT INCOME TAX WITHHOLDING ON

DISTRIBUTIVE SHARE INCOME REPORT AND COMPOSITE INCOME TAX RETURN

(To be completed by a Pass-through Entity Only)

KRS 141.206

➤ See instructions.

Taxable period beginning ___/___/2012, and ending ___/___/201___.

A Name of Pass-through Entity

B Federal Identification Number

C Kentucky Corporation/LLET

Number and Street

Account Number (if applicable)

City

State

ZIP Code

D Check applicable Boxes: ¨ Nonresident Income Tax Withholding on Distributive Share Income Report

¨ Change of name

¨ Amended - Nonresident Income Tax Withholding on Distributive Share Income Report

¨ Composite Income Tax Return

¨ Amended - Composite Income Tax Return

¨ Change of address

¨ Change of accounting period

¨ Final return

(1) Number of nonresident individuals, estates, trusts and corporations included in this withholding

on distributive share income report

(2) Number of nonresident individuals, estates, trusts and corporations exempt from this withholding

on distributive share income report

(3) Number of nonresident individuals, estates, and trusts included in this composite income tax return

(4) Kentucky distributive share income subject to withholding or included in the composite income tax

return before apportionment

(5) 100% or the apportionment fraction from the pass-through entity’s Schedule A, Section I, line 12

(6) Kentucky distributive share income subject to withholding or included in the composite income tax

return (line 4 multiplied by line 5)

(7) Tax before tax credits (line 6 multiplied by .06 (6%))

(8) Enter the partners’, members’ or shareholders’ nonrefundable tax credits

(9) Kentucky income tax liability (line 7 less line 8)

(10) Estimated tax payments

Check if Form 740NP-WH-P attached

(11) Extension payment

(12) Prior year’s tax credit

(13) Income Tax Due (line 9 less lines 10 through 12)

(14) Income tax overpayment (lines 10 through 12 less line 9)

(15) Credited to 2013

(16) Amount to be refunded (line 14 less line 15)

TAX PAYMENT SUMMARY

(Round to nearest dollar)

Make check(s) or money order(s)

payable to: Kentucky State Treasurer

Tax (Line (13))

$_____________________________

Mail to:

Penalty

$_____________________________

Kentucky Department of Revenue

Interest

$_____________________________

Frankfort, KY 40619-0006

Total Payment

$_____________________________

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

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

Print name of partner, member or shareholder

Signature of partner, member or shareholder

Daytime telephone number

Date

May the DOR discuss this return with the preparer?



Yes

Name of person or firm preparing return

Date

Email Address:

Telephone No.:

SSN, PTIN or FEIN

Form 740np-Wh - Kentucky Nonresident Income Tax Withholding On Distributive Share Income Report And Composite Income Tax Return - 2012

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