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Dealer:   E-Mail:  
Address:   Sales Tax Account Number:    
  Period Beginning (mm/dd/yyyy):    
City:   Period Ending (mm/dd/yyyy):     
Name of Airport:  

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INSTRUCTIONS: To ensure that the tax collected from sales of aviation fuel, including jet fuel, is properly credited to the Kentucky Aviation Economic Development Fund, provide the following information as requested below. Complete the information for each period for which the business files a sales and use tax return within 20 days following the Period Ending indicated above. Mail the completed schedule to the address below.

Kentucky Department of Revenue
Division of Sales and Use Tax
PO Box 181, Station 67
Frankfort, KY 40602-0181

Amount of taxable receipts included on line 22 of the sales tax return from sales of aviation fuel, including jet fuel $    
Gross Kentucky sales and use tax applicable to taxable aviation fuel receipts (line 1 x .06) $ 
Compensation (Deduct 1.75% of the first $1,000 and 1.5% of the amount in excess of $1,000 with a $50 cap. Total compensation may not exceed $50.) $ 
Net Kentucky sales and use tax for aviation fuel receipts (line 2 minus line 3) $

I declare, under penalties of perjury, that this schedule has been examined by me and, to the best of my knowledge and belief, it is true, correct and complete.

Signature Title Date (mm/dd/yyyy)
Phone (5025551234)no hyphens

NOTE: Entering your name will act as your "electronic signature"

This document is a supplementary schedule to be filed separately from and in addition to the company’s regular Kentucky sales and use tax return.

The Kentucky Transportation Cabinet, Division of Aviation, has advised that failure to complete the supplementary schedule may result in loss of current and future airport funding. 

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Please print this form for your records before submitting