Form 75a005 - Telecommunications Tax Complaint Form

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75A005 (4-11)
TeleCOmmUniCATiOns TAx
Commonwealth of Kentucky
COmplAinT FORm
DEPARTMENT OF REVENUE
Name and Mailing Address ____________________________________________________________________________
Contact Person_________________________ Phone Number________________ E-mail Address____________________
Agency ___________________________________________________________________________________________
Federal Identification Number (FEIN) ___________________________________________________________________
Agency Type (Check one)
 City (name) ________________________________________________________________________
 County (name) ______________________________________________________________________
 Sheriff (name) ______________________________________________________________________
 School District (name) _______________________________________________________________
 Special District (name) _______________________________________________________________
Name of Party Against Whom Complaint Filed ____________________________________________________________
FYE 6/30/2005 total franchise fee receipts certified to Department of Revenue (DOR):
1. Telecommunications/Telephone Franchise Fees ............................................. $ ______________________________
2. Multichannel Video Programming/Cable Franchise Fees ............................... $ ______________________________
3. Public, Educational or Governmental Fees (PEG Fees) ................................. $ ______________________________
4. Total Fees Certified to DOR ........................................................................ $ ______________________________
Hold Harmless Amount:
5. a. Total Franchise Fees Certified to DOR (line 4) ........................................... $ ______________________________
b. Franchise Portion of PSC Property Tax ...................................................... $ ______________________________
6. Total Amount for FYE 6/05 for Hold Harmless Computation
(line 5a plus line 5b) ........................................................................................ $ ______________________________
Distributions to Date:
7. Total payments from DOR received to date: ................................................... $ ______________________________
8. Number of payments received since January 2006 .........................................
______________________________
9. Total payments annualized ({line 7 / line 8} x 12) ......................................... $ ______________________________
Amount Over (Under) Hold Harmless:
10. Line 9 total minus line 6 total ......................................................................... $ ______________________________
Signature______________________________ Title _______________________________ Date___________
(continued on reverse)

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