42A816 (12-07)
Commonwealth of Kentucky               KEOZ ANNUAL REPORT
DEPARTMENT OF REVENUE

                                                                               Calendar Year_____________

Business Name                                               KEOZ Number        Kentucky Withholding
                                                                               Account Number
                                                           Activation Date

1. Total annual gross wages exclusive of any noncash
   benefits paid to eligible KEOZ employees only.          $

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

3. Total annual local KEOZ 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 paid exclusive of any noncash benefits,
              •     amount of Kentucky state tax withheld for the year, and
              •     amount of Kentucky KEOZ assessment claimed for the year.

                            KEOZ 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____________________________