Form 40a100 - Application For Refund Of Income Taxes

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40A100 (10-14)
A
F
PPLICATION
OR
*1400030027*
R
O
I
T
EFUND
F
NCOME
AXES
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
For Use by Individuals,
Fiduciaries and Corporations
Under the provisions of KRS 141.235 and Regulation 103 KAR 15:040, the undersigned taxpayer requests a refund of
income taxes paid as shown below:
Taxpayer Income Tax Account Number
1.
Name of taxpayer:
2. Address:
Number and street or rural route
City, town or post office
County
State
ZIP Code
3. Type of taxpayer (individual, fiduciary, corporation):
4. Taxable year involved (indicate dates of fiscal year, if applicable):
5. (a)
Amount of taxes paid with return and/or by declaration:
(b)
Amount of taxes paid on assessment (if applicable):
6. Dates of payment(s):
7.
Validation number imprinted by this department on each check used in making payments (if payment was made
by taxpayer’s check). If more than one payment was made, indicate each date and validation number separately:
8. Amount of tax refund requested:
9. Statement of taxpayer’s reasons for believing that a refund should be granted (attach schedule if necessary):
I, the undersigned, hereby certify that there is no tax liability for income taxes or any other taxes due or owing the Commonwealth of Kentucky by
this applicant, and declare under the penalties of perjury that I have examined this application (including any attached schedules and statements)
and to the best of my knowledge the statements contained herein are true, complete and correct.
Signature of individual taxpayer or fiduciary
Date
Spouse’s signature if tax paid by joint return
Signature of principal corporation officer or chief accounting officer
Date
Signature and firm or employer of preparer of this application if other than the taxpayer
Return to Kentucky Department of Revenue, Frankfort, KY 40620

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