Kentucky Appointment of Taxpayer Administrator and Authorized Users for Kentucky Online Tax

Appointment of Taxpayer Administrator and Authorized Users for Kentucky Online Tax
Form 10A106
10A106 (5-10)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE

Appointment of Taxpayer Administrator
and Authorized Users for
Kentucky Online Tax

FOR OFFICE USE ONLY
CRIS	

Entered by

CTS Person/Entity ID	

Date Entered

Need Help? Call (502) 564-2149
	 SECTION A	

BUSINESS / CONTACT INFORMATION

1.	

Legal Business Name__________________________________________________________________________________________________

2.	

Doing Business As ____________________________________________________________________________________________________

3.	

Federal Employer Identification Number (FEIN)

4.	

Coal Severance Tax Account Number

Supply a Contact with which the Department may discuss this Appointment form.
5.	

Contact Name	

6.	

Contact Title	

7.	

Contact E-mail Address

																			
8.	

Daytime Telephone (________) ________ – __________________    Extension ____________	

	 SECTION B	

9.	

@

Fax (________) ________ – __________________

OWNERSHIP DISCLOSURE–RESPONSIBLE PARTY UPDATE
Provide current information for the Responsible Parties for the Business listed in Section A.
(Officers for Corporations, Members for LLCs, Partners for Partnerships, Owner for Sole Proprietorships)

10.–15.

Name (Last, First, MI)

Business
Title

Daytime Phone
Number (include
area code)

Residential Address
City, State, Zip Code

E-mail Address

Social Security Number
(REQUIRED)

10A106 (5–10)

Page 2

	 SECTION C	

TAXPAYER ADMINISTRATOR APPOINTMENT
The person appointed as the Taxpayer Administrator will have access to all tax accounts and information for the Business listed in Section A.
To revoke Taxpayer Administrator access or appoint a new Taxpayer Administrator, the Business must contact the Department of Revenue.
(A business can only have one Taxpayer Administrator.)

16.

Name (Last, First, MI)

Online
Access
Role

Daytime Phone
Number (include
area code)

Residential Address,
City, State, Zip Code

E-mail Address

Social Security Number
(REQUIRED)

Taxpayer
Administrator

	 SECTION D	

AUTHORIZED USERS APPOINTMENT
The Taxpayer Administrator will grant access to specific accounts for the Business listed in Section A.
Authorized Users access may be revoked by the Taxpayer Administrator at any time.
(A business can have multiple Authorized Users.)

17.–21.

Name (Last, First, MI)

Online
Access
Role

Daytime Phone
Number (include
area code)

Residential Address,
City, State, Zip Code

E-mail Address

Social Security Number
(REQUIRED)

Authorized
User
Authorized
User
Authorized
User
Authorized
User
Authorized
User

		

IMPORTANT: THIS APPOINTMENT MUST BE SIGNED BELOW:

The statements contained in this appointment 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.
Signed:	

Signed:

Title:	

Title:

Date:	

 /     /

(mm/dd/yyyy)

Date:

 /     /

(mm/dd/yyyy)

For assistance in completing the application, please call the Kentucky Online Tax Help Desk at (502) 564-2149, Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.,
Eastern time.
MAIL completed form to:	
	
	

KENTUCKY DEPARTMENT OF REVENUE
P.O. BOX 1074, STATION 65
FRANKFORT, KENTUCKY 40602-1074

or
FAX to:	

(502) 564-0995