Form 10a104 - Update Or Cancellation Of Kentucky Tax Account(S) - 2017 Page 3
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410A104 (06-17)
Page 3
16.-17. OWNERSHIP DISCLOSURE—RESPONSIBLE PARTY UPDATE
Provide updated information for existing responsible parties or add additional responsible parties.
New Responsible Party
Update Existing
End Date
New Responsible Party
Update Existing
End Date
Full Legal Name (First, Middle, Last)
Full Legal Name (First, Middle, Last)
Social Security Number
FEIN (If Responsible Party is another
Social Security Number
FEIN (If Responsible Party is another
(REQUIRED)
business)
(REQUIRED)
business)
Driver’s License Number (if applicable)
Driver’s License State of Issuance
Driver’s License Number (if applicable)
Driver’s License State of Issuance
Business Title
Effective Date of Title (mm/dd/yyyy)
Business Title
Effective Date of Title (mm/dd/yyyy)
/
/
/
/
Residence Address
Residence Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
County (if in Kentucky)
Telephone Number
County (if in Kentucky)
(
)
–
(
)
–
Does this Responsible Party replace an existing one?
Does this Responsible Party replace an existing one?
Yes No
Yes No
Existing Responsible Party’s Name
End Date (mm/dd/yyyy)
Existing Responsible Party’s Name
End Date (mm/dd/yyyy)
/
/
/
/
SECTION F
UPDATE MAILING ADDRESS AND PHONE NUMBERS FOR TAX ACCOUNTS
18. Start Date for Address Change
20. List New Mailing Address
/
/
c/o or Attn.
19. Tax Accounts for which the Address Change Applies
Address
(Check all that apply)
Employer’s Withholding Tax
Consumer’s Use Tax
Corporation Income Tax
Sales and Use Tax
City
State
Zip Code
and/or Limited Liability
Transient Room Tax
Entity Tax
County (if in Kentucky)
Mailing Telephone Number
Motor Vehicle Tire Fee
Coal Severance and
(
)
–
Processing Tax
Commercial Mobile Radio
Note: To change the address or phone number for Telecommunications
Service (CMRS) Prepaid
Pass-Through Non-
Tax or Utility Gross Receipts License Tax, you must use the online system.
Service Charge Account
Resident Withholding
21. Start Date for Address Change
23. List New Mailing Address
/
/
c/o or Attn.
22. Tax Accounts for which the Address Change Applies
Address
(Check all that apply)
Employer’s Withholding Tax
Consumer’s Use Tax
Corporation Income Tax
Sales and Use Tax
City
State
Zip Code
and/or Limited Liability
Transient Room Tax
Entity Tax
County (if in Kentucky)
Mailing Telephone Number
Motor Vehicle Tire Fee
Coal Severance and
(
)
–
Processing Tax
Commercial Mobile Radio
Note: To change the address or phone number for Telecommunications
Service (CMRS) Prepaid
Pass-Through Non-
Tax or Utility Gross Receipts License Tax, you must use the online system.
Service Charge Account
Resident Withholding
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