42A806 (8-14)
Commonwealth of Kentucky             TRANSMITTER REPORT
DEPARTMENT OF REVENUE                FOR FILING KENTUCKY
                         W2/K2, 1099 AND W2-G STATEMENTS

 1. Withholding Account Name and Address        6. Number of Kentucky Statements

                                                7. Kentucky Taxable Wages/Distributions

 2. Please mark all that apply:                 8. Kentucky Income Tax Withheld
 £ W2/K2     £ 1099 £ W2-G
 3. KY Withholding Account Number               9. Name and Address of Transmitter

 4. Tax Year

 5. Phone Number (Include Area Code)            10. Contact Name for Submission

 DO NOT:

  Submit this Transmitter Report unless you are attaching Kentucky Paper Statements or a CD
  Staple
  File 1099’s unless Kentucky taxes have been withheld

 DO:
  Submit this Transmitter Report with Kentucky Paper Statements or CD by January 31 st of the following 
  calendar year
  Rubber band, paper clip or squeeze clip documents to this Transmitter Report

W2/K2 forms may be filed electronically in the Social Security Administration’s EFW2 format via the Kentucky 
Department of Revenue website.

1099’s and W2-G’s with state withholding may be filed electronically in IRS Publication 1220 format via CD only.

                                         Mailing Address:

                                  Kentucky Department of Revenue
                                         W-2 Processing
                                     501 High Street, Station 57
                                         Frankfort, KY  40601

                         Kentucky Department of Revenue Web Address:

                                     www.revenue.ky.gov