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APPLICATION FOR EXTENSION OF TIME

TO FILE INDIVIDUAL, GENERAL PARTNERSHIP AND

FIDUCIARY INCOME TAX RETURNS FOR KENTUCKY

40A102 (11-12)Commonwealth o Kentucky

DEPARTMENT OF REVENUE 2012

Last name First name (joint or combined return, give both names and initials) Your Social Security number

Mailing address (Number and Street including Apartment Number or P.O. Box) Spouses Social Security numbe

City, town or post ofce State ZIP code

Enter payment amount here ............... $

SECTION I(Please print or type name and address in block below.)

Check type o return:

Individual (740 or 740-NP) General Partnership (765-GP)

Fiduciary (741)

Soc. Sec. No. or Employer ID No.

A six-month extension is requested or fling the income tax return o the above-named taxpayer(s) or the taxable yea

ended .

REASON FOR REQUEST (A reason must be given beore any request can be considered. Inability to pay tax liability is not a val

reason.)

Signature o taxpayer Date Preparer other than taxpayer Date

Mail to: Kentucky Department o Revenue, P.O. Box 1190, Frankort, KY 40602-1190

DENIED: Late (postmarked after return due date) Other:

Use this orm i you (1) are requesting a Kentucky extension o time fle (complete Section I); (2) are requesting a Kentucky extension adesire to make a payment prior to the due date (complete Sections I anII); or (3) have a ederal extension and desire only to make a Kentucpayment prior to the due date (complete and submit Section II only

You will be notifed only i the application or extension is denied. avoid the late fling penalty, a copy o this orm must be attached your return when fled. Keep a copy or yoursel.

COMPLETE ONLY IF NOT FILING FEDERAL EXTENSION

SEE INSTRUCTIONS FOR PAYMENT REQUIREMENTS

INSTRUCTIONS:Taxpayers who request a ederal extension are notrequired to fle a separate Kentucky extension. The requirements maybe met by attaching ederal Form 4868 (automatic extension) to theKentucky return.

Interest at the annual rate o 6 percent applies to any income tax paidater the original due date o the return. I the amount o tax paid by theoriginal due date is less than 75 percent o the tax due, a late paymentpenalty may be assessed (minimum penalty is $10). Interest and latepayment penalty charges can be avoided by remitting payment with theExtension Payment Voucher below by the due date.

201240A102 (11-12)

SECTION IIKENTUCKY

EXTENSION PAYMENT VOUCHE

Make check payable to: Kentucky State Treasurer

Mail to: Kentucky Department o Revenue

P.O. Box 1190

Frankort, KY 40602-1190

*1200020028*

*1200020028*

To avoid the late fling penalty, a copy o this orm must be attached to your return when fled. Keep a copy or yoursel.

COMPLETE ONLY IF MAKING PAYMENT FOR INDIVIDUAL OR FIDUCIARY INCOME TAX