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Get KY 74A118 2019

Ax Mo. Yr. Account Number Check Here if Amended Return Check Here if Surplus Lines See reverse for information or call the Department of Revenue, (502) 564-4810. Name and Address Report for Month of Mo. / 20 NAIC FEIN 1. Total premiums (including those premiums not subject to surcharge deducted on Lines 2B and 2C), assessments and other charges collected on risk located in Kentucky (exclude municipal taxes.

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