10A104 (08-20)                              UPDATE OR CANCELLATION OF KENTUCKY TAX ACCOUNT(S)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE                                                                           FOR OFFICE USE ONLY
                                                                              CRIS                                   Coded / Entered / Date
•  Incomplete or illegible updates will delay processing and will be returned.
•  See instructions for questions regarding completion of this form.          Commonwealth Business Identifier (CBI) NAICS
•  Need Help?  Call (502) 564-2694 or visit www.revenue.ky.gov
                                                                              Federal Employer Identification Number (FEIN)

 SECTION A                                  REASON FOR COMPLETING THIS UPDATE (Must Be Completed)
   This Form may only be used to update current account information.          2. Effective Date       /                /
   To apply for additional accounts or to reinstate previous account          Check all that apply.
   numbers, use Form 10A100, Kentucky Tax Registration Application.               Update business name or DBA name
                                                                                  Update an existing location’s information for the
   1. Current Account Numbers                                                      Sales and Use Tax Account
                                                                                  Close a location of current business for the Sales and Use Tax
   Kentucky Employer’s Withholding Tax ____________________________                Account
   Kentucky Sales and Use Tax ___________________________________                 Open a new location of current business for the Sales and Use
   Kentucky Telecommunications Tax ______________________________                  Tax Account
   Kentucky Utility Gross Receipts License Tax _______________________            Add a mine location to an existing Coal Tax Account
   Kentucky Consumer’s Use Tax _________________________________                  Change accounting periods
   Kentucky Corporation Income Tax and/or                                         Change taxing election
    Kentucky Limited Liability Entity Tax ___________________________             Update/provide new responsible party information
   Kentucky Coal Severance and Processing Tax _____________________               Update mailing address(es) / mailing address telephone number(s)
   Kentucky Pass-Through Non-Resident WH ________________________                 Request cancellation of an account
                                                                                  Closing business / Close all tax accounts

  SECTION B                                        BUSINESS AND CONTACT INFORMATION (Must Be Completed)
3. Legal Business Name
    Current Name                                                              New Name (if applicable)
     ________________________________________________________                  ________________________________________________________________
     ________________________________________________________                  __________________________________________________________
4.  Doing Business As (DBA) Name
    Current DBA                                                               New DBA
     ________________________________________________________                  ________________________________________________________________
5.  Federal Employer Identification Number (FEIN)                             6. Kentucky Secretary of State Organization Number
    (Required, complete prior to submitting)                                   (If applicable)

7.  Commonwealth Business Identifier (CBI)

8.  Person to Contact Regarding this Update Form:
  Name (Last, First, Middle)                                        Title                 Daytime Telephone                         Extension
                                                                                          (        )                  –
  E-mail: (By supplying your e-mail address you grant the Department
  of Revenue permission to contact you via E-mail.)

10A104 (08-20)                                                                                                                                                  Page 2
  SECTION C                                               SALES AND USE TAX LOCATION INFORMATION
9.  Update or Close an existing Business Location for your Sales and Use Tax Account.
CURRENT LOCATION ADDRESS INFORMATION                                             NEW LOCATION ADDRESS INFORMATION
 Close Location      Update/Move    Location
   Business Location Name “Doing Business as” Name                                 Business Location Name “Doing Business as” Name

   Street Address (DO NOT List a PO Box)                                           Street Address (DO NOT List a PO Box)

   City                                   State           Zip Code                 City                                 State            Zip Code
                                                                                  
   County (if in Kentucky)                Location Telephone Number                County (if in Kentucky)              Location Telephone Number
                                          (               )                    –                                        (                )                    – 
   Date Location Closed (mm/dd/yyyy)
                  / / 

10. - 11. Opened a new Location(s) of Current Business
NEW LOCATION ADDRESS                                                             NEW LOCATION ADDRESS
   Business Location Name “Doing Business as” Name                                 Business Location Name “Doing Business as” Name

   Street Address (DO NOT List a PO Box)                                           Street Address (DO NOT List a PO Box)

   City                                   State           Zip Code                 City                                 State            Zip Code
                                                                                  
   County (if in Kentucky)                Telephone Number                         County (if in Kentucky)              Telephone Number
                                          (               )                    –                                        (                )                    – 
   Date Location Opened (mm/dd/yyyy)                                               Date Location Opened (mm/dd/yyyy)
                  / /                                                                             / / 
   Description of Business Activity Performed at Location                          Description of Business Activity Performed at Location
                                                                                  
  SECTION D                UPDATE ACCOUNTING PERIOD, OWNERSHIP TYPE, AND/OR RESPONSIBLE PARTIES
12.  Accounting Period change with the Internal Revenue Service (IRS)
   Accounting Period                  Calendar Year (year ending December 31st)                   Fiscal Year (year ending ___ ___/___ ___ (mm/dd))
                                      52/53 Week Calendar Year:                                    52/53 Week Fiscal Year: 
                                      December __________________________                          __________________________________________
                                                          (Day of Week that year ends)                     (Month & Day of Week that year ends)
13.  Taxing Election Change with the IRS
   (Note: If your Business Structure has changed, you are required to apply for new tax account numbers with the Department of 
   Revenue. Please complete Form 10A100, Kentucky Tax Registration Application.)
   A.  Current Business Structure ____________________________________________________________________

   B.  CURRENT TAXING ELECTION                                                          NEW TAXING ELECTION

         Partnership                                                                    Partnership
         Corporation                                                                    Corporation
         S-Corporation                                                                  S-Corporation 
         Cooperative                                                                    Cooperative
         Trust                                                                          Trust
         Single Member Disregarded Entity                                               Single Member Disregarded Entity
         (Member Federally Taxed as)                                                     (Member Federally Taxed as)
                   Individual Sole Proprietorship                                                  Individual Sole Proprietorship
                   General Partnership/Joint Venture                                               General Partnership/Joint Venture
                   Estate                                                                          Estate
                   Trust (non-statutory)/Business Trust                                            Trust (non-statutory)/Business Trust
                   Other ______________________________________                                    Other ______________________________________

10A104 (08-20)                                                                                                                                                      Page 3

14.-15.  OWNERSHIP DISCLOSURE—RESPONSIBLE PARTY UPDATE 
          Provide updated information for existing responsible parties or add additional responsible parties.

    New Responsible Party                  Update Existing     End Date             New Responsible Party                  Update Existing     EndDate
   Full Legal Name (First, Middle, Last)                                              Full Legal Name (First, Middle, Last)

   Social Security Number                     FEIN (If Responsible Party is another   Social Security Number                    FEIN (If Responsible Party is another
  (REQUIRED) business)                                                               (REQUIRED) business)

   Driver’s License Number (if applicable)    Driver’s License State of Issuance      Driver’s License Number (if applicable)   Driver’s License State of Issuance

   Business Title                             Effective Date of Title (mm/dd/yyyy)    Business Title                            Effective Date of Title (mm/dd/yyyy)
                                                        / /                                                                                 / /
   Residence Address                                                                  Residence Address

   City                                       State       Zip Code                    City                                      State       Zip Code
                                                                                     
   Telephone Number                           County (if in Kentucky)                 Telephone Number                          County (if in Kentucky)
    (     )                    –                                                       (          )                    –   
   Does this Responsible Party replace an existing one?                               Does this Responsible Party replace an existing one?
  Yes              No                                                              Yes              No     

   Existing Responsible Party’s Name          End Date (mm/dd/yyyy)                   Existing Responsible Party’s Name         End Date (mm/dd/yyyy)
                                                        / /                                                                                 / /
  SECTION E                                UPDATE MAILING ADDRESS AND PHONE NUMBERS FOR TAX ACCOUNTS
16.  Start Date for Address Change                                                     18.  List New Mailing Address
                                                                                      c/o or Attn.
           /           /                      
17.  Tax Accounts for which the Address Change Applies                               Address
    (Check all that apply)
                                                                                                                                 
     Employer’s Withholding Tax               Consumer’s Use Tax
     Sales and Use Tax                        Corporation Income Tax                City                                      State       Zip Code
                                               and/or Limited Liability              
     Transient Room Tax
                                               Entity Tax                             County (if in Kentucky)                   Mailing Telephone Number
     Motor Vehicle Tire Fee                   Coal Severance and                                                              (         )  – 
                                               Processing Tax
     Commercial Mobile Radio
          Service (CMRS) Prepaid               Pass-Through Non-                   Note: To change the address or phone number for Telecommunications 
          Service Charge Account               Resident Withholding                 Tax or Utility Gross Receipts License Tax, you must use the online system.

19.  Start Date for Address Change                                                     21.  List New Mailing Address
                                                                                      c/o or Attn.
           /           /                      
20.  Tax Accounts for which the Address Change Applies                               Address
    (Check all that apply)
                                                                                                                                 
     Employer’s Withholding Tax               Consumer’s Use Tax
     Sales and Use Tax                        Corporation Income Tax                City                                      State       Zip Code
                                               and/or Limited Liability              
     Transient Room Tax
                                               Entity Tax                             County (if in Kentucky)                   Mailing Telephone Number
     Motor Vehicle Tire Fee                   Coal Severance and                                                              (         )  – 
                                               Processing Tax
     Commercial Mobile Radio
          Service (CMRS) Prepaid               Pass-Through Non-                   Note: To change the address or phone number for Telecommunications 
          Service Charge Account               Resident Withholding                 Tax or Utility Gross Receipts License Tax, you must use the online system.

 10A104 (08-20)                                                                                                                                             Page 4

  SECTION F                                                REQUEST CANCELLATION OF ACCOUNT(S)
 22.  TAX ACCOUNTS FOR WHICH CANCELLATION IS REQUESTED                                 23.  REASON FOR CANCELLATION
     (Check all that Apply)
                                                                                                Business closed/No               Business sold (See #25)
      Employer’s Withholding Tax         Sales and Use Tax                                    further Kentucky activity 
      Consumer’s Use Tax                 Transient Room Tax                                   Ceased having employees          Ceased making retail and/or
                                                                                                                                   wholesale sales of tangible
      Motor Vehicle Tire Fee             Telecommunications Tax                               Death of owner                     personal property or digital
                                                                                                                                     property
      Utility Gross Receipts             Corporation Income Tax                               Converted to another 
         License Tax                           and/or Limited Liability                         ownership type and must          Merged out of existence
                                               Entity Tax                                       reapply for new accounts           (See #26)
      Coal Severance and                                                               
         Processing Tax                   Pass-Through Non-                                    No further Kentucky activity        Other (Specify):
                                               Resident Withholding                                                                   _________________________  
     
          Commercial Mobile Radio                                                                                                     _________________________
         Service (CMRS) Prepaid
         Service Charge Account                                                          NOTE:     A corporation’s or limited liability pass-through entity’s 
                                                                                         income tax/LLET account number is cancelled with the filing of the 
                                                                                         “final” return. A corporation or limited liability pass-through entity 
 24.  Effective Date to Cancel Account(s)                   /           /                organized in Kentucky shall not file a final return before it is officially 
                                                                                         dissolved pursuant to the provisions of KRS Chapter 14A.
 25.  If business sold, list the information for the new owner(s).
    Name                                                                         Name

   Address                                                                     Address 

    City                                 State             Zip Code             City                                         State         Zip Code
                                                                               
                                         Telephone Number                                                                    Telephone Number
                                         (     )                    –                                                     (          )                    – 
 26.  If merged out of existence, list the information for the new business.
   Business Name                                                                 Address

   FEIN                                                                         

    Telephone Number                                                            City                                         State         Zip Code
   (       )                    –                                              

                                          IMPORTANT: THIS UPDATE FORM MUST BE SIGNED BELOW:
 The statements contained in this Form and any accompanying schedules are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly 
 authorized to sign the Form.
 Printed Name: ______________________________________________________                    Printed Name: ______________________________________________________
 Signature: _________________________________________________________ Signature: _________________________________________________________
 Title: ______________________________________ Date: ____/____/______                    Title: ______________________________________ Date: ____/____/______
 Telephone Number: __________________________________________________                    Telephone Number: __________________________________________________
 For assistance in completing the Update Form, please call the Data Integrity Section  at(502) 564-2694, or you may use the Telecommunications Device for the Deaf. 
 SEND completed form to:                 KENTUCKY DEPARTMENT OF REVENUE                                    FAX to:        502-564-0796
                                         501 HIGH STREET, STATION 20A
                                         FRANKFORT, KENTUCKY 40601                                         EMAIL:         DOR.WEBResponseDataIntegrity@ky.gov

                                                                                                 The Kentucky Department of Revenue does not 
                                                                                                 discriminate on the basis of race, color, national origin, 
                                                                                                 sex, age, religion, disability, sexual orientation, gender 
                                                                                                 identity, veteran status, genetic information or ancestry 
                                                                                                 in employment or the provision of services.