MONTHLY REPORT FOR
DEALER LOANER/RENTAL VEHICLE TAX
FOR OFFICIAL USE ONLY
6 Tax 0 / Month
Make check payable to Kentucky State Treasurer and mail return with payment to: Kentucky Department of Revenue, Frankfort, KY 40619
TEAM KENTUCKY with payment to: Kentucky Department of Revenue, Frankfort, KY 40619 Account Number
Name of Business Enter Legal Name Loaner Number
Location of Business Month/ Year
Mailing Address P.O. Box or Number and Street Report and payment is due the 15th day of the month following the month reported.
Account Number
City State ZIP Code
LIST ANY ADDED OR REMOVED VEHICLES ON THE BACK OF THIS REPORT
Current Vehicles Used as Loaners/Rentals
Line # Vehicle Identification Number Line # Vehicle Identification Number
1 ---------- 12 ----------
2 ---------- 13 ----------
3 ---------- 14 ----------
4 ---------- 15 ----------
5 ---------- 16 ----------
6 ---------- 17 ----------
7 ---------- 18 ----------
8 ---------- 19 ----------
9 ---------- 20 ----------
10 ---------- 21 ----------
11 ---------- 22 ----------
VEHICLES MUST ALSO BE ADDED OR REMOVED IN AVIS THROUGH THE COUNTY CLERK'S OFFICE.
Number of Vehicles (Current + Added + Removed).......... ..........................................
Tax Due (multiply line 1 by 25.00)................. ..........................................
Adjustments (attach documentation)................. ..........................................
Interest (see instructions)......................... ..........................................
Penalty (see instructions)......................... ..........................................
Total Amount Due ........................... > ..........................................
The above statements are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly authorized to sign this report. Signature Title Date