Form 42A815 – Fill Out and Use This PDF

Name of

(

)

Business

Enter Exact Name as it Appears on Your Account (please print or type)

Telephone Number (include area code)

Mailing

Address

P.O. Box or Number and Street

City or Town

County

State

ZIP Code

(1)

Withholding tax account number under which tax was paid to the Kentucky State Treasurer

___________________________________

(2)

Period(s) in which tax was reported and paid __________________________________________________

(3)

Explain the reason(s) for refund (attach separate sheet if necessary) _______________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

(4)

Amount of tax refund requested ____________________________________________________________

(5)

Banking Information (if electronic fund transfer (EFT) requested)

Name of Bank __________________________________________________________________________

Depositor Account Number (DAN) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Checking

Routing Transit Number (RTN) __ __ __ __ __ __ __ __ __

Account Type ➤

Savings

Other

(1)

This application must be completed to receive the refund requested via EFT.

(2)

Only the taxpayer making payment of the tax directly to the Kentucky State Treasurer may file the application

for refund.

Instructions

(3)

Claims for refunds or credits must be filed within four years from the date the tax was paid to the State

Treasurer. After the statute of limitations has expired, no claims for refunds or credits will be considered.

(4)

Mail completed application to the Kentucky Department of Revenue, Withholding Tax Section, P.O. Box

181, Station 57, Frankfort, KY 40602-0181.

Signed

Title

Name

Date