FORM K-5
Commonwealth of Kentucky
Department of Revenue
KENTUCKY
EMPLOYER'S REPORT OF
WITHHOLDING TAX STATEMENTS

42A80518101
 
Kentucky Withholding Account Number
  Federal Employer Identification Number (FEIN)
 
Business Name
Mailing Address (Number and Street including Apartment Number or P.O. Box)
City, Town or Post Office
State
ZIP Code
Telephone Number

Part I — Kentucky Withholding Statement Code and Totals

Statement Code  
Number of Kentucky Withholding Statements  
Total Kentucky Wages or Payments  
Total Kentucky Tax Withheld  

Part II — Complete a line below for each Kentucky withholding statement issued. Another statement line will appear upon completion of the displayed lines once the Tab key is selected.

 
 
  Employee or Payee ID Number
(SSN or FEIN)
  Last Name
(Employee or Payee)
  Kentucky State
Wages or Payments
  Kentucky State
Income Tax Withheld
1  
 
     
2  
 
     
 
Under penalties of perjury, I declare that I have examined this form and the referenced KY withholding statements and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
I agree:     Yes     No  —  Select "YES" here to print or submit this on-line Form K-5.
Sign
Here
Signature of Taxpayer
Date
Name of Taxpayer
Title
Paid
Preparer
Use
Signature of Preparer
Date
Name of Preparer or Firm
ID Number
Email
Phone
May the DOR discuss this return with this preparer?
 Yes     No
 
 


The Kentucky Department of Revenue conducts work
under the authority of the Finance and Administration Cabinet.

© 2017 Commonwealth of Kentucky.  All rights reserved.

Kentucky.gov

Original text