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Unclaimed Property Holder Reporting Extension Request Form - Kentucky Department Of Treasury

UNCLAIMED PROPERTY

HOLDER REPORTING EXTENSION REQUEST FORM

Due by November 1, 2013

KENTUCKY DEPARTMENT OF TREASURY

DIVISION OF UNCLAIMED PROPERTY

1050 US HWY. 127 S., SUITE 100

FRANKFORT KY 40601

Current Fiscal Year representing property presumed abandoned during the Fiscal Year ended June 30.

State the reason(s) an extension is requested: ______________________________________________________

__________________________________________________________________________________________

Check the additional time requested to complete the report:

 30 days

 60 days

We are aware of Kentucky’s requirement to remit by November 1, the total (or best estimate) of

abandoned property owed in order to avoid possible penalties. This extension only applies to the filing of the

Holder Report Form.

I am duly authorized to execute this request for an extension by the holder.

Holder Name ______________________________ Date of Request ___________________________________

Contact Name _____________________________ FEIN ___________________________________________

Telephone No. _____________________________ Fax No. _________________________________________

Signature___________________________________ E-Mail: ________________________________________

DEPARTMENT USE ONLY

The following criteria will be considered in evaluating the request.

Adequate

Inadequate

Previous Filing History (if filed)

_______

Timeliness of Filing

_______

Previous Extension Requests (consecutive) _______

_______

_____________________________________________________

Date __________________

Department Staff Member

Extension Approved ___

Extension Denied ___

Report will be due on ______________

MAIL THIS FORM TO THE ABOVE ADDRESS OR FAX TO (502) 564-4200

Unclaimed Property Holder Reporting Extension Request Form - Kentucky Department Of Treasury