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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

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Line #	Vehicle Identification Number	Year	Make	Model	Mileage
73A055 (4-21)					Page 2
Vehicles ADDED as Loaners/Rentals
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Vehicles REMOVED as Loaners/Rentals
Line #	Vehicle Identification Number	Year	Make	Model	Mileage
1
Reason
2
Reason
3
Reason
4
Reason
5
Reason
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Reason
7
Reason
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Reason