42A808 (3-06)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE        Authorization to Submit Employees Annual
                              Wage and Tax Statements Via
                             Kentucky Department of Revenue Web Site

1. Check appropriate box:

† Initial request for PIN (personal identification number).

† Misplaced PIN.

† Request to change PIN due to security issue, i.e., new employee responsible for submitting W-2 information or
  PIN security has been compromised.

† FEIN changed, new PIN required.

2. Name, address and federal employer identification number of person, organization or firm
requesting Web filing:

Business Name _____________________________________        FEIN* ___________________________

Street Address ________________________________            City/State/ZIP_______________________________

3. Name, title and telephone number of contact person:

Contact Name ________________________________________      Phone Number_____________________

Title__________________________________          E-mail Address** __________________________________

4. Estimated number of wage and tax statements to be reported: ___________________________________

  Signature of Person Completing Authorization                       Date

Please submit the request to:
Kentucky Department of Revenue
Withholding Tax Branch
P.O. Box 181, Station 57
Frankfort, KY 40602-0181
www.revenue.ky.gov

*If more than one FEIN is involved, please use the FEIN of the submitting/transmitting entity.

**This gives Kentucky Department of Revenue permission to confirm the status to the employer using the
confidential e-mail address provided on the form.

Please Note: It is important to get your system/network administrator involved immediately to ensure that you have
the proper capabilities. Kentucky Department of Revenue provides a secure Web site, but there are often limitations
in your system or network. Please work with your system/network administrator early to ensure your success!