Form 51a109 - Application For Energy Direct Pay Authorization

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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

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