42A812 (12-07)
Commonwealth of Kentucky               KIDA ANNUAL REPORT
DEPARTMENT OF REVENUE

                                                                               Calendar Year_____________

Business Name                                               KIDA Number        Kentucky Withholding
                                                                               Account Number
                                                           Activation Date

1. Total annual gross wages paid to eligible KIDA
   employees only.                                         $

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

3. 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,
              •    amount of Kentucky state tax withheld for the year, and
              •    amount of Kentucky KIDA assessment claimed for the year.

                            KIDA 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____________________________