| TEAM\nKENTUCKY | with payment to: Kentucky Department of Revenue, Frankfort, KY 40619 | Account Number |
| Name of\nBusiness | Enter Legal Name | Loaner\nNumber | |
| Location of\nBusiness | | Month/\nYear | |
| Mailing\nAddress | P.O. Box or Number and Street | Report and payment is due the 15th day of the month following the month reported. |
| 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. |
| 1. Number of Vehicles (Current + Added + Removed).......... | .......................................... |
| 2. Tax Due (multiply line 1 by 25.00)................. | .......................................... |
| 3. Adjustments (attach documentation)................. | .......................................... |
| 4. Interest (see instructions)......................... | .......................................... |
| 5. 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.\n\nSignature Title Date |
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