Form 75a005 - Telecommunications Tax Complaint Form Page 2

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Please include or attach narrative explaining basis of complaint:
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________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Does complaint include request for substantial change due to enacting or modifying a franchise fee rate prior to June 30,
2005? If yes, please explain below:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Return form to:
Department of Revenue
ATTN: Local Distribution Fund Oversight Committee
P.O. Box 181
Frankfort KY 40602-0181

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