Form St Ar Obs - Application For Compensation Of Expenses Incurred For Origin-Based Sourcing Tax Collections Form - Department Of Taxation
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ST AR OBS
Department of
For State Use Only
Dev. 6/09
Taxation
State File No.
P.O. Box 530
Columbus, OH 43216-0530
Application for Compensation of Expenses
Incurred for Origin-Based Sourcing Tax Collections
This application is for submitting a request for compensation authorized under Ohio Revised Code section (R.C.) 5739.061.
Additional instructions are on page 2. THE ORIGINAL AND ONE COPY OF THIS FORM MUST BE FILED. ONLY ONE SET
OF BACK-UP DOCUMENTS IS NEEDED.
In order to qualify for compensation for expenses incurred as a result of switching to taxing sales of tangible personal property
based on origin (e.g., store location), as opposed to destination, the following criteria must be met:
• On and after July 1, 2009, a vendor that received temporary compensation for converting to destination-based sourcing
under R.C. 5739.123 as that section existed before its repeal by H.B. 429 of the 127th General Assembly may apply for
compensation.
• The compensation requested is for expenses incurred to comply with the requirement to convert back to origin-based
sourcing.
• This is a one-time compensation request. All expenses incurred to comply with origin-based sourcing must be included on
one compensation request per legal entity noted in #4 below. Any future compensation request fi led will be denied.
• The maximum compensation for vendors of tangible personal property that were required to comply with the destination-
sourcing provisions of divisions (C) to (I) of R.C. 5739.033 before the effective date, April 18, 2008, of R.C. 5739.061 is
$1,000.
• The maximum compensation for vendors of tangible personal property that irrevocably elected to comply with the destination-
sourcing provisions of divisions (C) to (I) of R.C. 5739.033 before the effective date, April 18, 2008, of R.C. 5739.061 is
$600.
• In no event shall a vendor receive compensation that exceeds its total cost of complying with the origin-based sourcing
requirements.
If the above criteria have not been met, you do not qualify for compensation of expenses incurred for collecting tax based
on origin and an application for compensation cannot be fi led.
Please type or print clearly
1. License number(s) on return used to remit origin-based sourcing tax
2. Name of applicant
3. Address
City
State
Zip
4. Federal employer identifi cation number or Social Security number
5. Total cost to switch to origin-based sourcing $
6. Amount requested for compensation on purchase(s) $
7. I hereby attest that I am the taxpayers(s) or their authorized agent. I declare under penalties of perjury that this claim
(including any accompanying schedules and statements) has been examined by me and, to the best of my knowledge
and belief, is true, correct and complete.
The taxpayers(s) will be represented in this matter by:
Name
Taxpayer
Address
Signature
Date
Telephone
Telephone
Fax
E-mail
E-mail
Central Offi ce Processing
Claimed
Inc/rec
Xfer ref
Net to txpr
Reviewer
Date
Check amount
Total approved
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