DECLARATION OF DOMICILE FOR PURCHASE OF RESIDENTIAL UTILITIES

Record Type Name

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

51A380 (1-23) - Commonwealth of Kentucky, Department of Revenue

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.

Accountholder Information

Kenergy Corp Account #

First Name

Last Name

Phone

Information of Person Completing Form

Are you the accountholder listed above?

YesNo

Relationship to Accountholder

First Name

Last Name

Phone

Service Address Information

Street

City

State Abbreviation

Zip Code

Service Description

Other

Declarant Information

Are you the resident of the domicile?

YesNo

Are you the landlord?

YesNo

Relationship to Resident

Form must be completed and signed by the resident or an applicable representative. Please contact the Kenergy office with any questions at 1-800-844-4832.

Declaration

I declare that the service address listed above is my place of domicile,* or the place of domicile of the resident named above, and that 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 that the account associated with the above listed service address be classified as exempt from sales and use tax. I understand that 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/Representative

Date

* 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.

Instructions

Submit this 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