Kentucky Application for Refund of Income Taxes

Application for Refund of Income Taxes
Form 40A100
FORM

40A100

APPLICATION FOR
REFUND OF INCOME TAXES

2023

AND LLET

Commonwealth of Kentucky
Department of Revenue

For Use by Individuals, Fiduciaries, Corporations, and Pass-Through Entities

Under the provisions of KRS 141.235, the undersigned taxpayer requests a refund of Income Tax/Limited Liability Entity Tax
(LLET) paid as shown below:
Kentucky Income Tax &/or LLET Account Number

1	 Name of taxpayer:
2	Address:
	
	

Number and street or rural route

City, town or post office	

County	

State	

ZIP Code

3	 Type of taxpayer:  ¨ individual  ¨ fiduciary  ¨ corporation  ¨ pass-through entity
4	 Taxable year involved (indicate dates of fiscal year, if applicable):
5	 a	

Amount of taxes paid with return and/or on extension:

	

b	

Amount of taxes paid on assessment (if applicable):

	
	

Note: For estimated payments made for tax year 2019 and thereafter, a Kentucky tax return must be filed to
request a refund of those payments. KRS 131.183(2)(d) and 141.044(2)(f)3.

6	 Dates of payment(s):
7	 Validation number imprinted by this department on each check used in making payments (if payment was made by
taxpayer’s check). If more than one payment was made, indicate each date and validation number separately:

8	 Amount of tax refund requested:
9	 Statement of taxpayer’s justification for refund request (attach schedule if necessary):

I, the undersigned, hereby certify that there is no tax liability for income taxes or any other taxes due or owing the Commonwealth of Kentucky by this applicant,
and declare under the penalties of perjury that I have examined this application (including any attached schedules and statements) and to the best of my
knowledge the statements contained herein are true, complete and correct.

Signature of taxpayer(s) or authorized person	

Date	

Spouse’s signature if tax paid by joint return	

Signature of principal corporation officer or chief accounting officer	

Date

Date

Signature and firm or employer of preparer of this application if other than the taxpayer

Return to Kentucky Department of Revenue, Frankfort, KY 40620

230027 40A100 (10-23)	

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