Form 51a125 - Application For Purchase Exemption Sales And Use Tax (2009)

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51A125 (12-09)
APPLICATION FOR PURCHASE EXEMPTION
Commonwealth of Kentucky
SALES AND USE TAX
DEPARTMENT OF REVENUE
This application should be fi led only by charitable, educational or religious institutions; historical sites; cemeteries; and units
of federal, state or local government.
IMPORTANT: See reverse side for instructions applicable to your organization before completing this application.
/
Name
Enter Exact Name of Organization
Phone Number
Location
Number and Street
City
County
State
Zip Code
Mailing Address
(If different from above)
City
County
State
Zip Code
P.O. Box or Number and Street
E-mail Address
Federal
Historical Site
Type of
State
Charitable
Organization
City
Educational
(Check One)
County
Religious
Special District
Cemetery
Administrative Division of Federal or State Unit,
Out-of-State Organization
City or County fi ling separate application
IMPORTANT—Give explanation of primary function(s). (Attach separate sheet if necessary.)
(1) Does the organization hold a sales and use tax permit?
Yes
No
Questionnaire
(2) Does the organization make any retail sales?
Yes
No
If yes, list type of sales
/
Authorized Purchasing Agent
Phone Number
Name
Title
/
Authorized Disbursement Agent
Title
Phone Number
Name
I hereby certify that the above statements are correct to the best of my knowledge and belief and that I am authorized
to sign this application. I agree that in the event it is determined that any of the property purchased is not tax-exempt,
I will immediately report and pay the required tax measured by the purchase price of this property.
Signed ______________________________________
Title _______________________________________
Date ________________________________________

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