51A109 (2-11)
APPLICATION FOR
ENERGY DIRECT PAY AUTHORIZATION
Commonwealth of Kentucky
(Sales and Use Tax and Utility Gross Receipts License Tax)
DEPARTMENT OF REVENUE
This form should be submitted only by persons engaged in the business of manufacturing, industrial processing, mining, or refining who document that the cost to them of
energy or energy-producing fuel exceeds 3 percent of the cost of production. A Retail Sales and Use Tax Permit must be obtained by all persons who obtain an Energy Direct
Pay Authorization. If you require a Retail Sales and Use Tax Permit and have not submitted a Kentucky Registration Application (Revenue Form 10A100), submit that form
with this application. If you choose to apply for the UGRLT exemption, you must register for a UGRLT number and you will be required to file monthly UGRLT
returns via KY E-Tax. **
Name of Business
(
)
Enter Exact Name of Business
Telephone Number
Location of Facility
(authorization is site specific)
Number and Street
City
County
State
ZIP Code
Mailing Address
(if different from above)
P.O. Box or Number and Street
City
County
State
ZIP Code
Nature of Business
IMPORTANT: An accurate description of your business is necessary.
at this Location
Are books kept on a calendar year basis? Yes
No
Questionnaire
(1)
If “No,” give fiscal year ending date: (Month)
(Day)
(2) Indicate the last period for which a Kentucky income tax return was filed.
(3) Was a balance sheet for the business included in the last income tax return filed? Yes
No
If “No,” submit a copy of the most recent balance sheet with this application.
(4)
How many business locations do you operate in Kentucky?
At how many of these locations do(es) manufacturing, industrial processing, mining, or refining occur?
(5)
In what school district is the plant facility located?
**
Identification
Utility Gross Receipts License Tax (UGRLT) Number
(if already issued)**
Numbers
Sales and Use Tax Permit Account Number
Kentucky Corporation Income Tax Number
Supplier and Amount
Type of Energy
Cost of Energy or
or Energy-Producing
Energy-Producing Fuel
of Energy or Energy-
Name of Supplier
Address of Supplier
Fuel Purchased
Purchased in Previous Year
Producing Fuel
(Submit copies of vendor
invoices)
Total Amount
Sales and Use Tax EDP Computation
(1) Cost of Production in Previous Year Excluding Cost of Energy or Energy-Producing Fuel............................................................ ______________________
(Attach separate schedule detailing Cost of Production) (See Instructions)
(2) Enter 3% of Cost of Production Excluding Energy or Energy-Producing Fuel (Line 1 x 3%) ........................................................ ______________________
(3) Estimated Monthly Cost of Energy or Energy-Producing Fuel Subject to Sales Tax (Line 2 ÷ 12) ................................................ ______________________
UGRLT EDP Computation**
**If you choose to apply for the UGRLT exemption, you must register for a UGRLT number and you will be required to file
monthly UGRLT returns electronically via KY E-Tax.**
Do you wish to apply for the UGRLT exemption at this time? Circle Yes or No ............................................................................. Yes
No
If “Yes”, then questions (4) through (9) must be completed for this document to be considered an application for UGRLT EDP.**
(4) Total Cost of Energy Purchased in Previous Year ............................................................................................................................ ______________________
(5) Less Energy not Subject to UGRLT (See Instructions) .................................................................................................................. ______________________
(6) Balance of Energy Subject to UGRLT (Line 4 - Line 5) .................................................................................................................. ______________________
(7) Cost of Production for UGRLT Computation (Line 1 + Line 5) ...................................................................................................... ______________________
(8) Enter 3% of Cost of Production for UGRLT (Line 7 x 3% ) ........................................................................................................... ______________________
(9) Estimated Monthly Cost of Energy Subject to UGRLT (Line 8 ÷ 12) ....................................................................................... ______________________
I hereby certify that the above statements are correct to the best of my knowledge and belief and that I am duly authorized to sign this application. I agree that, in consideration
for issuance of this Energy Direct Pay Authorization, I will directly report and pay to the Department of Revenue the sales or use tax and/or the UGRLT, on any energy or energy-
producing fuel purchased by me without payment of sales or use tax pursuant to KRS 139.480 and Regulation 103 KAR 30:140, and, if applicable, the UGRLT pursuant to KRS
160.613.
Mail to:
Kentucky Department of Revenue
Signature _____________________________________ Title ______________________________
Division of Sales and Use Tax
PO Box 181
Print Name ___________________________________ Date ______________________________
Frankfort, KY 40602-0181