An Official Website of the Commonwealth of Kentucky




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

If you wish to print this form and mail it in click here

INSTRUCTIONS: To ensure the tax collected from the sale of motor vehicles to residents of states which do not allow Kentucky residents to purchase motor vehicles without paying that state’s tax, or, which do not allow Kentucky residents to remove the vehicle from that state within a specific period for subsequent registration and use in Kentucky without payment of that state’s sales tax, you shall provide the following information pursuant to regulation. Complete the information for each period for which the business files a sales and use tax return within 20 days following the end of the filing period. Mail the completed schedule to the address below, or you may fax to (502) 564-2041, or you may e-mail to

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 returns from sales to customers that are residents of the following states:  Arizona, California, Florida, Indiana, Massachusetts, Michigan, South Carolina and Washington$    
Gross Kentucky sales and use tax (line 1 x .06)$ 
Claimed compensation (line 2) (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 collected from certain nonresident customers$

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.

Completion of this supplementary schedule is essential for proper crediting of sales tax collected to the state road fund.

Do Not Send Payment With This Form

Please print this form for your records before submitting