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CONTRACTOR AFFIDAVIT

DIRECTIVE TO CONTRACTORS THAT RECEIVE THIS AFFIDAVIT: The PEC (Project Exemption Certificate) Entity

identified in Part I failed to secure a timely PEC for the listed construction project. It is attempting to secure a refund of the

Kansas sales or use taxes that you paid or accrued on project materials, supplies, and labor services. While Kansas sales tax

law does not require you to assist the PEC Entity in securing this refund, you may choose to do so by completing this affidavit

and returning it, along with the required supporting documentation, to the PEC Entity identified in Part I.

PART I

– To be completed by the PEC Entity

1. PEC’s Name and Address: _______________________________________________________________________

____________________________________________________________________________________________

2. Nature of Project: ______________________________________________________________________________

(Roof repair, bathroom remodel, building addition, etc.)

3. Project Location: _______________________________________________________________________________

Street and City

4. Name of General Contractor on the Project: _________________________________________________________

5. Project’s begin and end dates: ____________________________________________________________________

PART II

– To be completed by the General Contractor and Subcontractors

6. Your Business Name and Address: ________________________________________________________________

____________________________________________________________________________________________

7. Did you receive a copy of: 1) Instructions for a PEC Entity refund; and 2) Schedule of Purchase Invoices, along with this

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Contractor Affidavit?

Yes

If no, please so indicate and return this form to the PEC Entity.

8. Do you wish to assist the PEC Entity in securing a refund of Kansas sales taxes that were paid because the PEC Entity did

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not secure a timely project exemption certificate?

Yes

No If no, please so indicate and return this form to the

PEC Entity.

9. Approximate dates that you worked on the Project identified in PART I: ____________________________________

10. Approximate payment you received for your work on the Project: $ ________________________

11. Your sales tax registration number (if you have one): ______________________

PART III –

Amount of Kansas Sales Tax You Paid or Accrued

12a. If you paid Kansas sales tax to your suppliers on materials and supplies used on the project, list your purchase invoices

on List of Purchase Invoices and attach copies of those invoices to the list. Please state the total amount of Kansas tax

that you paid on materials and supplies used on the Project: $ _____________________ .

12b. If you file sales tax returns and remitted sales tax to the Kansas Department of Revenue on services performed on the

project, please state the total amount of Kansas tax that you remitted on those services: $ ___________________ .

Please state the dates of the returns on which the tax was reported: _____________________________________ .

12c. If you file sales tax returns and report Kansas sales tax as a contractor-retailer and remitted sales tax to the Department

of Revenue on items taken from inventory for use on the project, please state the total amount of Kansas tax that you

accrued: $ _____________________________________ . Please state the dates of the returns on which the tax

was reported: _______________________________________________________________________________ .

Form St-21pec - Sales And Use Tax Refund Application For Use By Pec Entities Form - Kansas Page 2

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