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CCCCD CCCD CCD CCCCD AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAB CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCD AAAAAAAAAB 0 0 EFCEFCEFCD Year Ending Your Social Security No./FEIN LAST NAME FIRST NAME SPOUSE'S NAME Amount Paid Mailing Address (Number and Street including Apartment No. or P.O. Box) City, Town or Post Office Spouse's Social Security No. State Kentucky Department of Revenue Frankfort, KY 40620-0009 Zip Code Make check payable to: Kentucky State Treasurer. 42A740ES (09/22) DO NOT ATTACH CHECK TO V.

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