Form 10a104 - Update Or Cancellation Of Kentucky Tax Account(S)
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410A104 (6-11)
UPDATE OR CANCELLATION OF KENTUCKY TAX ACCOUNT(S)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
FOR OFFICE USE ONLY
CRIS
Coded / Date Coded
•
Incomplete or illegible updates will delay processing and will be returned.
•
Print or type using blue or black ink only.
CTS Person ID #
Entered / Data Entered
•
See instructions for questions regarding completion of this form.
NAICS
SIC
•
Need Help? Call (502) 564-2694 or visit
SECTION A
REASON FOR COMPLETING THIS UPDATE (Must Be Completed)
/
/
1. Effective Date
2. Current Account Numbers
Check all that apply.
Kentucky Withholding Tax
Updating business name or DBA name
Kentucky Corporation Income Tax
Updating an existing business location’s information under the
Kentucky Limited Liability Entity Tax
Sales and Use Tax account
Kentucky Sales and Use Tax
Opening a new location of current business for the Sales and Use
Kentucky Coal Severance Tax
Tax account
Kentucky Telecommunications Tax
Adding a Mine Location to an existing Coal Tax account
Kentucky Utility Gross Receipts License Tax
Changing accounting periods
This Form may only be used to update existing account
Updating ownership type for a taxing election change
Updating/providing new responsible party information
information. To apply for or reinstate accounts, use Form
Updating mailing address(es) / mailing address phone numbers
10A100, Kentucky Tax Registration Application.
Requesting cancellation of an account
SECTION B
BUSINESS AND CONTACT INFORMATION (Must Be Completed)
3. Legal Business Name
Current Name
New Name (if applicable)
________________________________________________________
_________________________________________________________________
________________________________________________________
__________________________________________________________
4.
Doing Business As (DBA) Name
Current DBA
New DBA
________________________________________________________
_________________________________________________________________
5.
Federal Employer Identification Number (FEIN)
6. Kentucky Secretary of State Organization Number
(Required, complete prior to submitting)
(If applicable)
—
7.
Person to Contact Regarding this Update Form:
Name (Last, First, Middle)
Title
Daytime Telephone
Extension
(
)
–
E-mail: (By supplying your e-mail address you grant the Department
of Revenue permission to contact you via E-mail.)
SECTION C
UPDATES TO SALES AND USE TAX LOCATION INFORMATION
8.
Update an existing Business Location for your Sales and Use Tax Account.
OLD LOCATION ADDRESS INFORMATION
NEW LOCATION ADDRESS INFORMATION
Business Location “Doing Business As Name”
Business Location “Doing Business As Name”
Street Address (DO NOT List a PO Box)
Street Address (DO NOT List a PO Box)
City
State
Zip Code
City
State
Zip Code
County (if in Kentucky)
Location Telephone Number
County (if in Kentucky)
Location Telephone Number
(
)
–
(
)
–
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