Form 55a001 - Application For Certificate Of Registration For Coal Severers And/or Processors
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1
255A001 (4-03)
DO NOT USE THIS SPACE
APPLICATION FOR CERTIFICATE OF REGISTRATION
Commonwealth of Kentucky
FOR COAL SEVERERS AND/OR PROCESSORS
Account
REVENUE CABINET
Number:
(Print or Type the Answers to Questions)
Answer all questions completely. Incomplete applications will be returned to you.
COMPLETE BUSINESS NAME AND LOCATION ADDRESS
MAILING ADDRESS (IF NOT SAME AS LOCATION ADDRESS)
Business Name
Federal ID Number
Mail To
Street Address or Route Number
Street Address or Post Office or Route Number
City
State
ZIP Code
City
State
ZIP Code
County
Telephone Number (Include Area Code)
County
Telephone Number (Include Area Code)
Date of
Date mining or processing operation began or will begin __________________________________
Business
o
o
o
o
o
Individual
Partnership
Limited Partnership
Corporation
Joint Venture
Type of
o
o
o
LLC
S Corporation
Other ______________________________________________
Ownership
(Give brief description)
For businesses that sever or process coal. Contract miners that do not have an economic
Nature of
interest in the coal mined are not liable for severance tax.
Business
o
a. Severs coal in Kentucky.
o
b. Processes coal in Kentucky.
Location of Business
List the mines that you operate in Kentucky and complete continuation on page 2 if necessary.
Surface Disturbance
Kentucky Department
MSHA
Location
Contract
Mining Permit
of Mines and
Identification
Mine Name
(County)
Miner Name
Number
Minerals File Number
Number
15-
15-
15-
(Continued on page 2)
Location of
____________________________________________________________________________________________________
Records
Street
City or Town
County
State
ZIP Code
Name and address of previous owner, if any ___________________________________________
Previous
Owner
_______________________________________________________________________________
o
o
Are you entitled to the depletion allowance under Section 611 of the Internal Revenue Code?
Yes
No
If no, who is? (Name and address) ______________________________________________________________________
IMPORTANT: APPLICATION MUST BE SIGNED BELOW.
The above statements are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly authorized
to sign this application. Signature of owner or all partners required. If a corporation, an officer must sign. (Attach separate sheet if
necessary.)
Signed __________________________________________
Signed _________________________________________
Title _________________________ Date _____________
Title _________________________
Date ___________
Signed __________________________________________
Signed _________________________________________
Title _________________________ Date _____________
Title _________________________
Date ___________
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