Form 75a900 - Telecommunications Tax Application

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75A900 (12-05)
FOR OFFICIAL USE ONLY
TELECOMMUNICATIONS
Commonwealth of Kentucky
Account Number
DEPARTMENT OF REVENUE
TAX APPLICATION
Status
Frequency
Business Name
FEIN __ __ – __ __ __ __ __ __ __
Address
Mailing
Address
Address
City
State
ZIP Code
Address
Location
Address
Address
City
State
ZIP Code
Liability Date
__ __ / __ __ / __ __ __ __
Company Type
Muncipal Utility
Other Provider
Consumer
(Select Only One)
Proprietor
Corporation
S Corporation
Government
Association
Ownership Type
Fiduciary
Joint Venture
Real Estate Investment Trust
Trust
Nonprofit
(Select Only One)
General Partnership
Limited Partnership
LLP
LLC, tax as _____________
Telecommunications Services
Multi-channel Video Programming
Service Type
(Select Only One)
Direct Broadcast Satelitte
Multiple Services
Contact Person
SSN __ __ __ – __ __ – __ __ __ __
Name
Address
Street
Address
Address
City
State
ZIP Code
Daytime Phone
(
)
–
Fax (
)
–
E-mail Address
Position Title
Start Date
/
/
I hereby certify that the above statements are correct to the best of my knowledge and belief and that I am duly authorized to sign this application.
Mail to:
Kentucky Department of Revenue
Signature
Title
Sales and Use Tax Division
P O Box 181, Station 67
Frankfort, KY 40602-0181
Print Name
Date
Phone (502) 564-5170, option 2

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