Form 72a303 - Election Application/cancellation Form printable pdf download

72A303 (9-06)

Commonwealth of Kentucky

Election Application/Cancellation Form

DEPARTMENT OF REVENUE

Name of Business

Mailing Address

City

State

ZIP Code

Federal ID Number

An election for exemption shall be made on an annual basis and shall be for a calendar year.

2. At the conclusion of the year, the election for exemption shall continue for the next calendar year unless the

dealer notifies the Department of Revenue of the dealer’s intention to void the election for exemption by January

15th of the next calendar year.

3. If the election for exemption is voided, the provisions of KRS 138.330 immediately apply.

4. A dealer electing to be exempted from the provisions of KRS 138.330 shall file with the department a financial

instrument in an amount not to exceed two months’ estimated liability, as calculated by the department, or

$5,000, whichever is greater.

5. In addition to the provisions of KRS 138.210 to 138.340 the dealer shall certify to the department no later than

the 15th day of each month the amount of gasoline and special fuels tax due the commonwealth by the 25th day

of that month.

6. The certification shall be submitted via an electronic method acceptable by both the dealer and the department.

By certifying the amount of tax which is to be remitted to the department, the dealer agrees to initiate an

Automated Clearing House credit transaction to electronically transfer the amount of tax from the dealer’s

account to the Kentucky State Treasurer on the 25th day of that month.

8. If the dealer fails to certify the amount of tax collected as prescribed by this section or does not perform the

electronic fund transfer, the department may immediately make demand on the financial instrument and revoke

the license of the dealer notwithstanding the provisions of KRS 138.340.

Gasoline Dealer’s License Number

Special Fuels Dealer’s License Number

Begin election January 1 of the next

calendar year.

Cancel election January 1 of the next

calendar year.

Signature ________________________________________

Date ____________________________________

Owner, Partner, or Corporate Officer

Mail completed application to Kentucky Department of Revenue, Motor Fuels Tax Compliance Section,

P .O. Box 1303, Station 63, Frankfort, KY 40602-1303.

Form 72a303 - Election Application/cancellation Form