Wyoming Department of Revenue
Excise Tax Division
122 West 25th St., Herschler Bldg.
Cheyenne, WY 82002-0110
Statement of Usage for Power or Fuel
Social Security Number
Purchaser Name(s)
Mailing Address
Physical Address
Telephone(s)
FAX Number(s)
Sales Tax License No.:
Note: Use of power or fuel for domestic, industrial, or commercial consumption is subject to sales tax.
Please check the type of Power or Fuel Purchased:
(Check more than one, if applicable)
Electricity
Natural Gas
Propane/LPG
Diesel
Other
The above Power Purchased Exempt from Sales Tax under W.S. 39-15-105 for reason that the same is consumed directly in:
(Check One)
Manufacturing
Processing
Agriculture
Generation of Motive Power for Transportation
Power or Fuel purchased exempt from sales tax must be metered or stored separately from power or fuel which is used in a taxable fashion.
Please list the meter number(s), or the physical delivery location and describe the separate storage facility below. Briefly describe your
percentage of exempt power or fuel consumed as outlined in W.S. 39-15-105(a)(iii)(A-F)
%
%
%
%
%
Check this box if the exempt use is measured by a Engineered Calculation (More Information on Reverse Side of this form)
The undersigned purchaser hereby certifies that the
above information given to obtain this exemption is true
and correct. If such power or fuel is converted to a
taxable use, the purchaser acknowledges that they will
be directly liable for remitting to the Department any and
all taxes, penalties and interest due.
Signed:________________________________________
(Must be Authorized Representative of Purchasing Firm)
Title:________________________________________________________
Date:________________________________________________________
See Instructions on Reverse Side of this Form
ETS Form 102 (revised 3/23/98)