Form 62A376 – Fill Out and Use This PDF

Social Security No. or

Name of Taxpayer(s)

Telephone Number

ORGANIZATION

TYPE

Federal ID No.

Work

ο

Individual

1

Home

2nd SSN if joint return

ο

Joint (Co-owners)

2

Number and Street or Box Number

ο Partnership/LLP

3

ο Domestic Corp./

County of residence or

business location

LLC

4

City or Town

State

ZIP Code

ο Foreign Corp./

Did you list intangibles

Yes

No

LLC

5

in other KY counties?

ο Fiduciary–Bank

6

(check one)

Is this a first-year listing?

ο Yes

ο No

ο Fiduciary–Other

7

1

STOCKS, MUTUAL FUNDS, OPTIONS AND WARRANTS

The St. Ledger court decision invalidated intangible tax on stocks, and any investment consisting of stocks such as IRAs. This includes

mutual funds, options and warrants.

2

MONEY MARKET ACCOUNTS

Money market accounts are nontaxable intangible assets.

3

(A)

(B)

(C)

(D)

(E)

(F)

BONDS

Interest

Maturity

Face

Number

Value

Value

CUSIP NO.

Rate

Date

Value

Owned

of Each

(Col. D x Col. E)

4

LOANS, NOTES AND MORTGAGES RECEIVABLE, AND LAND CONTRACTS

Enter name and address of grantee or debtor, and date payable. Under “Type,” indicate whether loans, notes and

mortgages are: (1) secured; (2) unsecured; (3) insured or guaranteed; or (4) insolvent or being foreclosed.

(A)

(B)

(C)

(D)

For Office

Type

Name and Address of Grantee or Debtor

Original

Credits

Face Value

Taxable

Use Only

Face Value

to Date

(Col. A – Col. B)

Value

Total all items in Sections 3 and 4 and Carry Forward to Reverse Side ....................... ➤

$

Value

For Office

as of Jan. 1

Use Only

Total of Sections 3 and 4 from Front Page

➤ $

5

TRUSTS: (List full value of corpus for: (1) Irrevocable Trusts held in Kentucky with Ken-

Value

tucky life tenant(s) and (2)

all Revocable Trusts if the settlor is a Kentucky resident.)

as of Jan. 1

Type

FEIN No.

Attach list of taxable intangible assets held by trust.

6

CASH AND DEPOSITS (See Instructions, Section 6)

Value

(1)

.......................................Money in hand as of January 1 (including money in a safe deposit box)

(2)

.....................................Money on deposit with nonbanking financial institutions as of January 1

(3)

......................................................Life insurance proceeds subject to withdrawal as of January 1

(4)

Future lump sum payment: Date Due

............................................

(5)

Retail Repurchase Agreements

7

For Sections 7 and 8, secured receivables are taxable

OTHER RECEIVABLES

at 100 percent of face value. Unsecured receivables at

Face Value (Jan. 1)

Taxable Value

85 percent of face value.

and miscellaneous

$

.........GRAND TOTAL OF SECTIONS 3–7 (Intangibles Subject to 25¢ State Rate Only)

➤

8

INTANGIBLES—Subject to 1½¢ State Rate Only

Face Value (Jan. 1)

Taxable Value

(Attach schedules if more than one item)

(1)

Accounts receivable, notes, bonds, credits, etc., arising out of or created

in the course of regular and continuing business transactions

substantially performed outside this state (attach schedule)

$

(2)

Intercompany accounts between parent and subsidiaries (parent

owns 80 percent or more of subsidiaries (attach schedule)

$

(3)

RIGHTS, ROYALTIES, PATENTS, COPYRIGHTS, ETC

(4)

TOBACCO BASE ALLOTMENTS (attach schedule)

TOTAL FOR SECTION 8 (Intangibles Subject to 1½¢ State Rate Only)

➤

RETIREMENT PLANS OR ANNUITIES (Right to Receive Income)/

9 INTANGIBLE PROPERTY OF BANKS

Value

(Subject to 1/10¢ State Rate Only)

Annual Income

(1)

Life: Age or date of birth of recipient

$

Annual Income

Term: Date last payment due

$

(2)

Non-Kentucky irrevocable trust

Annual Income

with Kentucky beneficiary

$

(3)

Retirement (IRAs, etc.), pension and profit-sharing plans, deferred compensation

(4)

Intangible property of banks (HB 416, 1996)

TOTAL FOR SECTION 9 (Intangibles Subject to 1/10¢ State Rate Only)

.........................

➤

Signature of Taxpayer

Date

Name of Preparer Other Than Taxpayer

Signature of Co-Owner

Date

Date