Schedule Ci (Form 41a720-Ci) - Application For Coal Incentive Tax Credit
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220__ __
Schedule CI
*1200020221*
41A720–CI (10–12)
Commonwealth of Kentucky
Calendar Year
DEPARTMENT OF REvENuE
A
F
C
I
T
C
PPlICATION
OR
OAl
NCENTIvE
Ax
REDIT
➤ See instructions.
KRS 141.0405
➤ For Coal Purchased During Calendar Year
Name of Entity
Federal Identification Number
__ __ __ __ __ __ __ __ __
Number and Street
Kentucky Corporation/LLET Account Number
__ __ __ __ __ __
City
State
ZIP Code
Telephone Number (Include Area Code)
Corporation
Limited Liability Pass-through Entity
General Partnership
Type of Entity (check applicable box) :
Other ➤
__ __ __ __ __ __
__ __ __ __ __ __
Kentucky Corporation/LLET Account Number (if applicable)
GNC Number
PART I—Qualifying Tons of Coal Purchased During the Base Year (Calendar Year 1999)
A
B
C
D
Name and Kentucky Coal Severance Tax Account
For Department of
Qualifying Tons of
Number of Taxpayer Subject to Kentucky
Revenue use Only
Name of Supplier
Coal Purchased
Coal Severance Tax On Qualifying Coal Purchases
Approved Tons Purchased
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11. Total Approved Tons for the Base Year ..........................................................................................................
PART II—Qualifying Tons of Coal Purchased During the Current Calendar Year
A
B
C
D
Name and Kentucky Coal Severance Tax Account
For Department of
Qualifying Tons of
Name of Supplier
Number of Taxpayer Subject to Kentucky
Revenue use Only
Coal Purchased
Coal Severance Tax On Qualifying Coal Purchases
Approved Tons Purchased
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11. Total Approved Tons for the Current Calendar Year ......................................................................................
I, the undersigned, declare under the penalties of perjury, that I have examined this application, including all accompanying schedules and statements,
and to the best of my knowledge and belief, it is true, correct and complete.
Signature of Principal Officer or Chief Accounting Officer
Date
Type or Print Name and Title of Principal Officer or Chief Accounting Officer
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