Form Lgt 140 - City, County, Or Urban County Government Insurance Premium Tax Annual Reconciliation Page 3

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SECTION III
CARRIER LISTING FOR EXPORTED COVERAGE
If reporting as a surplus lines broker pursuant to KRS 304.10, please list the carriers that supplied the coverage for which the premiums
*
and taxes are being reported.
Carrier Name
NAIC
Annual
Municipal
Carrier Name
NAIC
Annual
Municipal
No.
Premium
Taxes
No.
Premium
Taxes
Collected
Collected
Collected
Collected
Total
* If additional space is needed to list exported carriers, please list the carrier name, NAIC number, and the amount of annual premium collected on a separate
sheet of paper and submit the information with the completed Form LGT 141.
SECTION IV – CERTIFICATION
I hereby certify that the informa tion provided is an accurat e statement of the premiums collected and that the true and correct amount of taxes
due have been remitted to the city, county, or urban county government named above.
________________________________________________________________________
Date: ______________
Signature of Person Responsible for Preparing This Return/Title

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