Declaration of Domicile for Purchase of Residential Utilities

DECLARATION OF DOMICILE FOR PURCHASE OF RESIDENTIAL UTILITIES

(LANDLORDS OR OTHER ACCOUNTHOLDERS OF MULTI-UNIT DWELLINGS SERVED BY A SINGLE METER (MASTER METER) USE THE MULTI-UNIT DECLARATION OF DOMICILE)

In accordance with the provisions of KRS 139.470(7) this declaration may only be executed for the purchase of sewer services, water, and fuel by Kentucky residents for use in heating, water heating, cooking, lighting, and other residential uses. “Fuel” shall include but not be limited to natural gas, electricity, fuel oil, bottled gas, coal, coke, and wood.

Your Information

Account Number

Accountholder Name

is the accountholder for

Service Address

City/Town

State/Province

ZIP/Postal Code

Name of Individual Signing the Declaration (cannot be landlord)

am the resident or

Relationship of the undersigned to the resident

Signature

I declare that the address listed is my place of domicile* or the place of domicile* of

Name of Resident

and the purchase of residential utilities for use at this address meets the qualifications for exemption from Kentucky sales and use tax under KRS 139.470(7). Accordingly, I request the account associated with the above listed service address be classified as exempt from sales and use tax. I understand the exemption will begin on the date of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative. Under penalties of perjury, I swear or affirm that the information on this declaration is true and correct as to every material matter.

Signature of Resident or Representative

Sign above

Date Submitted:

* KRS 139.470(7) describes a place of domicile as “the place where an individual has his or her legal, true, fixed and permanent home and principal establishment, and to which, whenever the individual is absent, the individual has the intention of returning.”

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Instructions

• Submit the Declaration of Domicile to each applicable utility provider or rural electric cooperative, not to the Department of Revenue.

• Each resident may have only one place of domicile but may be listed as a responsible party for other service addresses.

• The change in taxability for accounts will be effective on the first day of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative.

Department of Revenue Contact Information:

Phone: 502-564-5170

Email: DOR.Webresponsesalestax@ky.gov