Fillable 10A104 (Commonwealth of Kentucky)

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10A104 (Commonwealth of Kentucky)

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The 10A104 (Commonwealth of Kentucky) form is 4 pages long and contains:

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  • 39 check-boxes
  • 200 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Kentucky

BROWSE COMMONWEALTH OF KENTUCKY (KY) FORMS

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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.)
( ) –
UPDATE OR CANCELLATION OF KENTUCKY TAX ACCOUNT(S)
CRIS Coded / Entered / Date
Commonwealth Business Identifier (CBI)
NAICS
Federal Employer Identification Number (FEIN)
FOR OFFICE USE ONLY
• Incomplete or illegible updates will delay processing and will be returned.
• See instructions for questions regarding completion of this form.
• Need Help? Call (502) 564-2694 or visit www.revenue.ky.gov
SECTION A REASON FOR COMPLETING THIS UPDATE (Must Be Completed)
2. Effective Date
Check all that apply.
Update business name or DBA name
Update an existing location’s information for the
Sales and Use Tax Account
Close a location of current business for the Sales and Use Tax
Account
Open a new location of current business for the Sales and Use
Tax Account
Add a mine location to an existing Coal Tax Account
Change accounting periods
Change taxing election
Update/provide new responsible party information

Update mailing address(es) / mailing address telephone number(s)
Request cancellation of an account
SECTION B BUSINESS AND CONTACT INFORMATION (Must Be Completed)
/ /
10A104 (06-17)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
This Form may only be used to update current account information.
To apply for additional accounts or to reinstate previous account
numbers, use Form 10A100, Kentucky Tax Registration Application.
—
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. Commonwealth Business Identifier (CBI)
8. Person to Contact Regarding this Update Form:
Kentucky Employer’s Withholding Tax ____________________________
Kentucky Sales and Use Tax ___________________________________
Kentucky Telecommunications Tax ______________________________
Kentucky Utility Gross Receipts License Tax _______________________
Kentucky Consumer’s Use Tax _________________________________
Kentucky Corporation Income Tax and/or
Kentucky Limited Liability Entity Tax ___________________________
Kentucky Coal Severance and Processing Tax _____________________
Kentucky Pass-Through Non-Resident WH ________________________
1. Current Account Numbers
Mine Name
Mine Number
Mine Location (County)
Surface Disturbance Mining Permit Number (if available)
Contract Miner Business Name (if available)
Contract Miner Federal Employer Identification Number (FEIN)(if available)
SECTION C ADD A NEW MINE LOCATION TO AN EXISTING COAL TAX ACCOUNT
9. LIST THE MINE LOCATIONS THAT YOU OPERATE IN KENTUCKY
10. Do you operate additional mine locations? Yes No
If yes, attach a listing of the information in Question 9 for each Kentucky mine location.
SECTION D SALES AND USE TAX LOCATION INFORMATION
Business Location Name “Doing Business as” Name
Street Address (DO NOT List a PO Box)
City State Zip Code
County (if in Kentucky) Location Telephone Number
Date Location Closed (mm/dd/yyyy)
/ /
Business Location Name “Doing Business as” Name
Street Address (DO NOT List a PO Box)
City State Zip Code
County (if in Kentucky) Location Telephone Number
( ) – ( ) –
CURRENT LOCATION ADDRESS INFORMATION
Close Location Update/Move Location
NEW LOCATION ADDRESS INFORMATION
11. Update or Close an existing Business Location for your Sales and Use Tax Account.
10A104 (06-17) Page 2
Business Location Name “Doing Business as” Name
Street Address (DO NOT List a PO Box)
City State Zip Code
County (if in Kentucky) Telephone Number
Date Location Opened (mm/dd/yyyy)
/ /
Description of Business Activity Performed at Location
( ) –
NEW LOCATION ADDRESS
Business Location Name “Doing Business as” Name
Street Address (DO NOT List a PO Box)
City State Zip Code
County (if in Kentucky) Telephone Number
Date Location Opened (mm/dd/yyyy)
/ /
Description of Business Activity Performed at Location
( ) –
NEW LOCATION ADDRESS
12. - 13. Opened a new Location(s) of Current Business
SECTION E UPDATE ACCOUNTING PERIOD, OWNERSHIP TYPE, AND/OR RESPONSIBLE PARTIES
14. Accounting Period change with the Internal Revenue Service (IRS)
Accounting Period Calendar Year (year ending December 31
st
) Fiscal Year (year ending ___ ___/___ ___ (mm/dd))
52/53 Week Calendar Year: 52/53 Week Fiscal Year:
December __________________________ __________________________________________
(Day of Week that year ends) (Month & Day of Week that year ends)
15. Taxing Election Change with the IRS
(Note: If your Business Structure has changed, you are required to apply for new tax account numbers with the Department of
Revenue. Please complete Form 10A100, Kentucky Tax Registration Application.)
A. Current Business Structure ____________________________________________________________________
B. CURRENT TAXING ELECTION NEW TAXING ELECTION
Partnership
Corporation
S-Corporation
Cooperative
Trust
Single Member Disregarded Entity
(Member Federally Taxed as)
 Individual Sole Proprietorship
 General Partnership/Joint Venture
 Estate
 Trust (non-statutory)/Business Trust
 Other ______________________________________
Partnership
Corporation
S-Corporation
Cooperative
Trust
Single Member Disregarded Entity
(Member Federally Taxed as)
 Individual Sole Proprietorship
 General Partnership/Joint Venture
 Estate
 Trust (non-statutory)/Business Trust
 Other ______________________________________
10A104 (06-17) Page 3
16.-17. OWNERSHIP DISCLOSURE—RESPONSIBLE PARTY UPDATE
Provide updated information for existing responsible parties or add additional responsible parties.
Full Legal Name (First, Middle, Last)
Social Security Number FEIN (If Responsible Party is another
(REQUIRED) business)
Driver’s License Number (if applicable) Driver’s License State of Issuance
Business Title Effective Date of Title (mm/dd/yyyy)
/ /
Residence Address
City State Zip Code
Telephone Number County (if in Kentucky)
Does this Responsible Party replace an existing one?
Yes No
Existing Responsible Party’s Name End Date (mm/dd/yyyy)
/ /
Full Legal Name (First, Middle, Last)
Social Security Number FEIN (If Responsible Party is another
(REQUIRED) business)
Driver’s License Number (if applicable) Driver’s License State of Issuance
Business Title Effective Date of Title (mm/dd/yyyy)
/ /
Residence Address
City State Zip Code
Telephone Number County (if in Kentucky)
Does this Responsible Party replace an existing one?
Yes No
Existing Responsible Party’s Name End Date (mm/dd/yyyy)
/ /
( ) – ( ) –
New Responsible Party Update Existing End Date New Responsible Party Update Existing End Date
18. Start Date for Address Change
19. Tax Accounts for which the Address Change Applies
(Check all that apply)
21. Start Date for Address Change
22. Tax Accounts for which the Address Change Applies
(Check all that apply)
20. List New Mailing Address
23. List New Mailing Address
/ /
/ /
c/o or Attn.
Address
City State Zip Code
County (if in Kentucky) Mailing Telephone Number
c/o or Attn.
Address
City State Zip Code
County (if in Kentucky) Mailing Telephone Number
( ) –
( ) –
SECTION F UPDATE MAILING ADDRESS AND PHONE NUMBERS FOR TAX ACCOUNTS
Note: To change the address or phone number for Telecommunications
Tax or Utility Gross Receipts License Tax, you must use the online system.
Note: To change the address or phone number for Telecommunications
Tax or Utility Gross Receipts License Tax, you must use the online system.
Employer’s Withholding Tax
Sales and Use Tax
Transient Room Tax
Motor Vehicle Tire Fee
Commercial Mobile Radio
Service (CMRS) Prepaid
Service Charge Account
Consumer’s Use Tax
Corporation Income Tax
and/or Limited Liability
Entity Tax
Coal Severance and
Processing Tax
Pass-Through Non-
Resident Withholding
Employer’s Withholding Tax
Sales and Use Tax
Transient Room Tax
Motor Vehicle Tire Fee
Commercial Mobile Radio
Service (CMRS) Prepaid
Service Charge Account
Consumer’s Use Tax
Corporation Income Tax
and/or Limited Liability
Entity Tax
Coal Severance and
Processing Tax
Pass-Through Non-
Resident Withholding
10A104 (06-17) Page 4
IMPORTANT: THIS UPDATE FORM MUST BE SIGNED BELOW:
The statements contained in this Form and any accompanying schedules are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly
authorized to sign the Form.
Printed Name: ______________________________________________________ Printed Name: ______________________________________________________
Signature: _________________________________________________________ Signature: _________________________________________________________
Title: ______________________________________ Date: ____/____/______ Title: ______________________________________ Date: ____/____/______
Telephone Number: __________________________________________________ Telephone Number: __________________________________________________
For assistance in completing the Update Form, please call the Data Integrity Section at (502) 564-2694, or you may use the Telecommunications Device for the Deaf.
SEND completed form to: KENTUCKY DEPARTMENT OF REVENUE FAX to: 502-564-0796
P.O. BOX 299, STATION 20A
FRANKFORT, KENTUCKY 40602-0299 EMAIL: DOR.WEBResponseDataIntegrity@ky.gov
24. TAX ACCOUNTS FOR WHICH CANCELLATION IS REQUESTED
(Check all that Apply)
SECTION G REQUEST CANCELLATION OF ACCOUNT(S)
25. REASON FOR CANCELLATION
 Business closed/No Business sold (See #27)
 further Kentucky activity
 Ceased having employees Ceased making retail and/or
wholesale sales of tangible
 Death of owner personal property or digital
property
 Converted to another
 ownership type and must Merged out of existence
reapply for new accounts (See #28)
 No further Kentucky activity Other (Specify):
_________________________
_________________________
/ /
26. Effective Date to Cancel Account(s)
27. If business sold, list the information for the new owner(s).
28. If merged out of existence, list the information for the new business.
Name
Address
City State Zip Code
Telephone Number
( ) –
Address
City State Zip Code
Name
Address
City State Zip Code
Telephone Number
( ) –
Business Name
FEIN
Telephone Number
( ) –
The Kentucky Department of Revenue does not
discriminate on the basis of race, color, national origin,
sex, age, religion, disability, sexual orientation, gender
identity, veteran status, genetic information or ancestry
in employment or the provision of services.
NOTE: A corporation’s or limited liability pass-through entity’s
income tax/LLET account number is cancelled with the filing of the
“final” return. A corporation or limited liability pass-through entity
organized in Kentucky shall not file a final return before it is officially
dissolved pursuant to the provisions of KRS Chapter 14A.
Employer’s Withholding Tax
Consumer’s Use Tax
Motor Vehicle Tire Fee
Utility Gross Receipts
License Tax
Coal Severance and
Processing Tax
Commercial Mobile Radio
Service (CMRS) Prepaid
Service Charge Account
Sales and Use Tax
Transient Room Tax
Telecommunications Tax
Corporation Income Tax
and/or Limited Liability
Entity Tax
Pass-Through Non-
Resident Withholding
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Completed 18 July 2020

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