Form 62a863 - Financial Institutions Local Deposits Summary Report

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62A863 (11-14)
FINANCIAL INSTITUTIONS
Commonwealth of Kentucky
LOCAL DEPOSITS SUMMARY REPORT
DEPARTMENT OF REVENUE
FOR 20___
Office of Property Valuation
501 High Street, Fourth Floor, Station 32
(ANNUAL FRANCHISE TAX)
Frankfort, KY 40601-2103
Name ___________________________________________________________________________
FEIN ___________________
Mailing Address _____________________________________________________________________________________________
City __________________________________ State ___________________ ZIP Code ____________ County _____________
Per KRS 136.575 each financial institution shall file with the Department of Revenue, Office of Property Valuation, Frankfort,
Kentucky 40601-2103 on or before August 15 of each year, a report of all deposits located within this commonwealth as of
the preceding June 30. Read the instructions on the reverse side carefully before preparing this return.
TOTAL DEPOSITS
1. Demand deposits of individuals, partnerships and corporations ........................................................ $
2. Time deposits of individuals, partnerships and corporations ..............................................................
3. Deposits of the United States government (including postal savings) ................................................
4. Deposits of state and political subdivisions .............................................................................................
5. Deposits of other banks and trust companies ..........................................................................................
6. Deposits of public schools and libraries ...................................................................................................
7. Deposits of religious and charitable institutions ATTACH SCHEDULE ...........................................
8. Other deposits (certified and officers' checks) ATTACH SCHEDULE ...............................................
9. Total deposits (add lines 1 through 8) ......................................................................................................
DEPOSITS NOT SUBJECT TO TAX
10. Deposits of the United States government (including postal savings) ................................................
11. Deposits of state and political subdivisions .............................................................................................
12. Deposits of other banks and trust companies ..........................................................................................
13. Deposits of public schools and libraries ...................................................................................................
14. Deposits of religious and charitable institutions ATTACH SCHEDULE ...........................................
15. Other deposits (certified and officers' checks) ATTACH SCHEDULE ..............................................
16. Total exempt deposits (add lines 10 through 15) .....................................................................................
17. Net deposits (subtract line 16 from line 9) ...............................................................................................
A copy of the most recent summary of deposits filed with the Federal Deposit Insurance Corporation must be attached
for this form to be valid.
I declare, under the penalties of perjury, that this report (including any accompanying schedules and statements) is correct and com-
plete.
_______________________________________________________________
________________________________________
Signature of Taxpayer
Name of Preparer Other Than Taxpayer
_______________________________________________________________
________________________________________
Telephone Number of Taxpayer
Date
_______________________________________________
______________________________
________________________
Contact Person (Print)
Telephone Number
Date
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