62A863 (11-14)                                 FINANCIAL INSTITUTIONS
Commonwealth of Kentucky
DEPARTMENT OF REVENUE                    LOCAL DEPOSITS SUMMARY REPORT
Office of Property Valuation                           FOR 20___
501 High Street, Fourth Floor, Station 32
Frankfort, KY 40601-2103                       (ANNUAL FRANCHISE TAX)

Name ___________________________________________________________________________        FEIN ___________________

Mailing Address _____________________________________________________________________________________________

City __________________________________ State ___________________   ZIP Code ____________  County _____________

 Per KRS 136.575 each financial institution shall file with the Department of Revenue, Office of Property Valuation, Frankfort, 
Kentucky 40601-2103 on or before August 15 of each year, a report of all deposits located within this commonwealth as of 
the preceding June 30. Read the instructions on the reverse side carefully before preparing this return.

                                               TOTAL DEPOSITS
 1.  Demand deposits of individuals, partnerships and corporations ........................................................ $
 2.  Time deposits of individuals, partnerships and corporations ..............................................................  
 3. Deposits of the United States government (including postal savings) ................................................   
 4.  Deposits of state and political subdivisions .............................................................................................   
 5.  Deposits of other banks and trust companies ..........................................................................................   
 6.  Deposits of public schools and libraries ...................................................................................................   
 7.  Deposits of religious and charitable institutions ATTACH SCHEDULE ...........................................   
 8.  Other deposits (certified and officers' checks) ATTACH SCHEDULE ...............................................   
 9. Total deposits (add lines 1 through 8) ...................................................................................................... 
  
                                         DEPOSITS NOT SUBJECT TO TAX

10.  Deposits of the United States government (including postal savings) ................................................   
11.  Deposits of state and political subdivisions .............................................................................................   
12.  Deposits of other banks and trust companies ..........................................................................................   
13.  Deposits of public schools and libraries ...................................................................................................   
14.  Deposits of religious and charitable institutions ATTACH SCHEDULE ...........................................   
15. Other deposits (certified and officers' checks) ATTACH SCHEDULE  ..............................................   
16.  Total exempt deposits (add lines 10 through 15) .....................................................................................   
17. Net deposits (subtract line 16 from line 9) ...............................................................................................
A  copy of the most recent summary of deposits filed with the Federal Deposit Insurance Corporation must be attached 
for this form to be valid.
I declare, under the penalties of perjury, that this report (including any accompanying schedules and statements) is correct and com-
plete.
_______________________________________________________________        ________________________________________
                         Signature of Taxpayer                                      Name of Preparer Other Than Taxpayer

_______________________________________________________________       ________________________________________ 
                Telephone Number of Taxpayer                                            Date

_______________________________________________         ______________________________ ________________________
      Contact Person (Print)                           Telephone Number                                                                             Date
                                         Go to www.revenue.ky.gov to download forms.

                      INSTrUCTIONS
                      FINANCIAL INSTITUTIONS
                      LOCAL DEPOSITS SUmmAry rEPOrT

Each financial institution shall file with the Department of Revenue, on or before August 15 of 
each year, a report of all deposits located within this commonwealth as of the preceding June 
30, along with a copy of the most recent summary of deposits filed with the Federal Deposit 
Insurance Corporation.

These deposits should be listed in detail on a separate schedule whenever the words "attach 
schedule" appear opposite the line number.

Line 9, the total of all deposits on lines 1 through 8, should reconcile with "Total Deposits All 
Offices" as reported to the Federal Deposit Insurance Corporation on OMB 3064-0061, "Sum-
mary of Deposits."

Deposits not subject to tax should be classified as outlined on lines 10 through 15.

Any financial institution with multiple branches should complete and attach Schedule A.

The completed return should be sent to:

                      Kentucky Department of revenue
                      Office of Property Valuation
                      Public Service Branch
                      501 High Street, Fourth Floor, Station 32
                      Frankfort, Kentucky 40601-2103