Commonwealth of Kentucky 657 Chamberlin Ave Frankfort, KY 40601 Phone: 5 0 2 - 564 - 5550 A p repaid char ge of $.75 per copy is required (Payable by Check or Money Ord er to Kentucky State Treasurer ). Include a self - addressed, stampe d envelope with the request. Previously Filed Form 4 /Form 5 Request Date: Requesting: Form 4 (Notice of Rejection) Form 5 (Notice of Withdrawal) : Company Name : Phone Number : Address : Social Security Number : Approximate File Date: Business Name: Address: Signature: Please note a ll requests require pre - payment. Records will be mailed once payment is received. Records are not faxed or electronically transferred. Mail Request, Payment, and Self - Addressed Stamped Envelope to: Attention: Compliance Bra nch 657 Chamberlin Ave Frankfort, KY 40601 * E ffective October 11, 2010 there will be a $3 5.00 fee on all returned checks . * American LegalNet, Inc. www.FormsWorkFlow.com