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

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