Form 4 Details

Kentucky Form 5 is a document that tax preparers use to calculate the amount of tax that individuals and businesses owe to the state. The form can be complex, so it is important to understand how to complete it correctly. In this blog post, we will provide an overview of how to fill out Kentucky Form 5. We will also discuss some of the common errors that taxpayers make when completing the form. By understanding these errors, you can avoid them and ensure that your tax return is accurate.

You will discover information regarding the type of form you wish to submit in the table. It will show you how much time it will require to complete kentucky form 5, exactly what parts you will have to fill in and several further specific facts.

QuestionAnswer
Form NameKentucky Form 5
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesFRANKFORT, workers compensation form 4, kentucky workers' compensation forms, ACKNOWLEDGMENT

Form Preview Example

FORM NO. 5

WRITTEN NOTICE OF WITHDRAWAL (REV. 7/97)

DEPARTMENT OF WORKERS CLAIMS

1270 LOUISVILLE ROAD

FRANKFORT, KENTUCKY 40601

WRITTEN NOTICE OF WITHDRAWAL OF FORM 4 REJECTION

EMPLOYER DATA:

FEDERAL ID# _____________________________

EMPLOYER NAME ____________________________________________________ PHONE NO. ________________________

STREET ADDRESS __________________________________________________________________________________________

CITY, STATE, ZIP ___________________________________________________________________________________________

NATURE OF BUSINESS ____________________________________

#OF EMPLOYEES ________________________________

EMPLOYEE DATA:

NAME ______________________________________ SOCIAL SECURITY NUMBER _________________________________

STREET ADDRESS ______________________________________________ EMPLOYEE PHONE NO. ____________________

CITY, STATE, ZIP ___________________________________________________________________________________________

I HEREBY WISH TO NOTIFY THE ABOVE LISTED EMPLOYER THAT I WISH TO WITHDRAW MY EMPLOYEE’S WRITTEN NOTICE OF REJECTION EFFECTIVE__________________________. THE REJECTION NOTICE WAS FILED WITH THE DEPARTMENT OF WORKERS

CLAIMS ON OR ABOUT_________ (YEAR). I NOW WISH TO BE COVERED UNDER THE PROVISIONS OF THE KENTUCKY REVISED

STATUTES CHAPTER 342, COMMONLY KNOWN AS THE WORKERS’ COMPENSATION ACT. I HAVE FILED THIS FORM WITH MY EMPLOYER ON THIS DATE.

 

_____________________________________________________________

 

EMPLOYEE SIGNATURE

DATE

STATE OF ______________________

 

 

COUNTY OF ____________________

 

 

SUBSCRIBED AND SWORN TO BEFORE ME BY ___________________________________________________ TO BE

 

 

EMPLOYEE NAME

 

HIS/HER VOLUNTARY ACT AND DEED, ON THIS______________DAY OF______________________________ , _________.

 

____________________________________

________________________________________

 

NOTARY PUBLIC

MY COMMISSION EXPIRES:

 

ACKNOWLEDGMENT OF RECEIPT AND FILING

I,_______________________________________________________HEREBY ACKNOWLEDGE THAT THE ABOVE-MENTIONED EMPLOYEE

FILED THIS WITHDRAWAL OF THE NOTICE OF REJECTION WITH HIS/HER EMPLOYER ON THE __________________________DAY OF

_________________, _________, AND THAT THE ORIGINAL OF THIS FORM WAS MAILED TO THE DEPARTMENT OF WORKERS CLAIMS

ON THIS DATE.

BY: ___________________________________________________________________________

EMPLOYER

TITLE

DATE

INSTRUCTIONS FOR WITHDRAWAL OF

EMPLOYEE’S WRITTEN NOTICE OF REJECTION

Pursuant to KRS 342.395(3), withdrawal of the notice of rejection shall not be effective as to any injury sustained or disease incurred less than one (1) week after notice is filed with the employer.

The employer must file the original of this form with the Department of Workers Claims. Forms should be mailed to: Department of Workers Claims, ATTENTION: Enforcement

Branch, 1270 Louisville Road, Frankfort, Kentucky 40601.

If you want to have the filing of the withdrawal acknowledged by the Department, you must forward with the original, a photostatic copy and a self-addressed stamped envelope.

If you have any questions, please contact the Enforcement Branch at (800) 731-5241.