42A814 (12-07)
Commonwealth of Kentucky               KIRA ANNUAL REPORT
DEPARTMENT OF REVENUE

                                                                               Calendar Year_____________

Business Name                                              KIRA Number         Kentucky Withholding
                                                                               Account Number
                                                           Activation Date

1. Total annual gross wages subject to income tax
   paid to eligible KIRA employees only.                   $

2. Total annual Kentucky KIRA assessments
   claimed by your company. (Include pending
   refunds requested for assessments not retained
   by company.)                                             $

3. Total annual local KIRA assessments claimed
   by your company, if applicable.                          $

4. Total annual Kentucky tax withheld and reported
   under this account number for all employees,
   eligible and ineligible.                                $

           Please attach spreadsheet that lists for each eligible employee the following information:
              •     name,
              •     Social Security number,
              •     state of residency,
              •     annual gross wages subject to income tax paid,
              •     amount of Kentucky state tax withheld for the year, and
              •     amount of Kentucky KIRA assessment claimed for the year.

                            KIRA Annual Report is due by March 15 of each year.

           Mail to:      Kentucky Department of Revenue
                         Tax Credits Section
                         P.O. Box 181, Station 52
                         Frankfort, KY 40602-0181

           Fax to:       (502) 564-0058

           E-mail to:    KRC.WEBResponseEconomicDevelopmentCredits@ky.gov

Signature _______________________________________________              Date ___________________________________

Title ____________________________________________________             E-Mail _________________________________

Telephone Number ______________________________________                Fax Number____________________________