10A104 (08-20) UPDATE OR CANCELLATION OF KENTUCKY TAX ACCOUNT(S)

Commonwealth of Kentucky
DEPARTMENT OF REVENUE FOR OFFICE USE ONLY
CRIS Coded / Entered / Date
• Incomplete or illegible updates will delay processing and will be returned.

• See instructions for questions regarding completion of this form. Commonwealth Business Identifier (CBI) NAICS

• Need Help? Call (502) 564-2694 or visit www.revenue.ky.gov

Federal Employer Identification Number (FEIN)

SECTION A REASON FOR COMPLETING THIS UPDATE (Must Be Completed)

This Form may only be used to update current account information. 2. Effective Date /        /
To apply for additional accounts or to reinstate previous account Check all that apply.
numbers, use Form 10A100, Kentucky Tax Registration Application.  Update business name or DBA name
 Update an existing location’s information for the
1. Current Account Numbers Sales and Use Tax Account
 Close a location of current business for the Sales and Use Tax
Kentucky Employer’s Withholding Tax_____________________________ Account
Kentucky Sales and Use Tax____________________________________  Open a new location of current business for the Sales and Use
Kentucky Telecommunications Tax_______________________________ Tax Account
Kentucky Utility Gross Receipts License Tax________________________  Add a mine location to an existing Coal Tax Account
Kentucky Consumer’s Use Tax__________________________________  Change accounting periods
Kentucky Corporation Income Tax and/or  Change taxing election
Kentucky Limited Liability Entity Tax____________________________  Update/provide new responsible party information
Kentucky Coal Severance and Processing Tax______________________  Update mailing address(es) / mailing address telephone number(s)
Kentucky Pass-Through Non-Resident WH_________________________  Request cancellation of an account
 Closing business / Close all tax accounts

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. Commonwealth Business Identifier (CBI)

8. 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.)
10A104 (08-20) Page 2
SECTION C SALES AND USE TAX LOCATION INFORMATION
9. Update or Close an existing Business Location for your Sales and Use Tax Account.
CURRENT LOCATION ADDRESS INFORMATION NEW LOCATION ADDRESS INFORMATION
 Close Location    Update/Move Location
Business Location Name “Doing Business as” Name Business Location Name “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
( ) – ( ) –
Date Location Closed (mm/dd/yyyy)
/ /

10. - 11. Opened a new Location(s) of Current Business

NEW LOCATION ADDRESS NEW LOCATION ADDRESS
Business Location Name “Doing Business as” Name Business Location Name “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) Telephone Number County (if in Kentucky) Telephone Number
( ) – ( ) –
Date Location Opened (mm/dd/yyyy) Date Location Opened (mm/dd/yyyy)
/ / / /
Description of Business Activity Performed at Location Description of Business Activity Performed at Location

SECTION D UPDATE ACCOUNTING PERIOD, OWNERSHIP TYPE, AND/OR RESPONSIBLE PARTIES

12. Accounting Period change with the Internal Revenue Service (IRS)
Accounting Period  Calendar Year (year ending December 31st)  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)

13. 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  Partnership
 Corporation  Corporation
 S-Corporation  S-Corporation
 Cooperative  Cooperative
 Trust  Trust

 Single Member Disregarded Entity  Single Member Disregarded Entity

(Member Federally Taxed as) (Member Federally Taxed as)
 Individual Sole Proprietorship  Individual Sole Proprietorship
 General Partnership/Joint Venture  General Partnership/Joint Venture
 Estate  Estate
 Trust (non-statutory)/Business Trust  Trust (non-statutory)/Business Trust
 Other_______________________________________  Other_______________________________________
10A104 (08-20) Page 3

14.-15. OWNERSHIP DISCLOSURE—RESPONSIBLE PARTY UPDATE

Provide updated information for existing responsible parties or add additional responsible parties.

 New Responsible Party    Update Existing   End Date  New Responsible Party    Update Existing   End Date

Full Legal Name (First, Middle, Last) Full Legal Name (First, Middle, Last)

Social Security Number FEIN (If Responsible Party is another Social Security Number FEIN (If Responsible Party is another
(REQUIRED) business) (REQUIRED) business)

Driver’s License Number (if applicable) Driver’s License State of Issuance Driver’s License Number (if applicable) Driver’s License State of Issuance

Business Title Effective Date of Title (mm/dd/yyyy) Business Title Effective Date of Title (mm/dd/yyyy)

/ / / /
Residence Address Residence Address

City State Zip Code City State Zip Code

Telephone Number County (if in Kentucky) Telephone Number County (if in Kentucky)

( ) –   ( ) –  

Does this Responsible Party replace an existing one? Does this Responsible Party replace an existing one?
Yes    No  Yes    No 

Existing Responsible Party’s Name End Date (mm/dd/yyyy) Existing Responsible Party’s Name End Date (mm/dd/yyyy)

/ / / /

SECTION E UPDATE MAILING ADDRESS AND PHONE NUMBERS FOR TAX ACCOUNTS
16. Start Date for Address Change 18. List New Mailing Address

/         / c/o or Attn.

17. Tax Accounts for which the Address Change Applies Address
(Check all that apply)

 Employer’s Withholding Tax  Consumer’s Use Tax
 Sales and Use Tax  Corporation Income Tax City State Zip Code
and/or Limited Liability
 Transient Room Tax Entity Tax County (if in Kentucky) Mailing Telephone Number
 Motor Vehicle Tire Fee  Coal Severance and ( ) –
Processing Tax
 Commercial Mobile Radio
Service (CMRS) Prepaid  Pass-Through Non- Note: To change the address or phone number for Telecommunications
Service Charge Account Resident Withholding Tax or Utility Gross Receipts License Tax, you must use the online system.

19. Start Date for Address Change 21. List New Mailing Address

/         / c/o or Attn.

20. Tax Accounts for which the Address Change Applies Address
(Check all that apply)

 Employer’s Withholding Tax  Consumer’s Use Tax
 Sales and Use Tax  Corporation Income Tax City State Zip Code
and/or Limited Liability
 Transient Room Tax Entity Tax County (if in Kentucky) Mailing Telephone Number
 Motor Vehicle Tire Fee  Coal Severance and ( ) –
Processing Tax
 Commercial Mobile Radio
Service (CMRS) Prepaid  Pass-Through Non- Note: To change the address or phone number for Telecommunications
Service Charge Account Resident Withholding Tax or Utility Gross Receipts License Tax, you must use the online system.
10A104 (08-20) Page 4

SECTION F REQUEST CANCELLATION OF ACCOUNT(S)

22. TAX ACCOUNTS FOR WHICH CANCELLATION IS REQUESTED 23. REASON FOR CANCELLATION
(Check all that Apply)
 Business closed/No  Business sold (See #25)
 Employer’s Withholding Tax  Sales and Use Tax further Kentucky activity

 Consumer’s Use Tax  Transient Room Tax  Ceased having employees  Ceased making retail and/or
wholesale sales of tangible
 Motor Vehicle Tire Fee  Telecommunications Tax  Death of owner personal property or digital
property
 Utility Gross Receipts  Corporation Income Tax  Converted to another
License Tax and/or Limited Liability ownership type and must  Merged out of existence
Entity Tax reapply for new accounts (See #26)
 Coal Severance and
Processing Tax  Pass-Through Non-  No further Kentucky activity  Other (Specify):

Resident Withholding __________________________
 Commercial Mobile Radio
__________________________
Service (CMRS) Prepaid
Service Charge Account 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
24. Effective Date to Cancel Account(s) /         / organized in Kentucky shall not file a final return before it is officially
dissolved pursuant to the provisions of KRS Chapter 14A.
25. If business sold, list the information for the new owner(s).

Name Name

Address Address

City State Zip Code City State Zip Code

Telephone Number Telephone Number

( ) – ( ) –

26. If merged out of existence, list the information for the new business.

Business Name Address

FEIN

Telephone Number City State Zip Code

( ) –

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
501 HIGH STREET, STATION 20A
FRANKFORT, KENTUCKY 40601 EMAIL: [email protected]

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.