51A380 (1-23)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE

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DECLARATION OF DOMICILE FOR PURCHASE OF RESIDENTIAL UTILITIES

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.

Name of the Account Holder

First

Last

Account Number

Email

Phone

Service Address

Address Line 1

City

State

Zip Code

SERVICE ADDRESS: 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.”

I,

First

Last

am the resident or am the responsible party for resident, and declare that the address listed is my place of domicile* or the place of domicile* of

Name of Resident (if you are responsible party)

First

Last

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.

IMPORTANT NOTICE TO CUSTOMER

By signing below, you agree to the following

1. The information supplied is accurate as of the date shown; 2. The parties agree that the electronic signatures appearing on this form are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. 3. 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.

Signature

Clear Signature

Typed Name

Date / Time of Form Submission

Date

Time

Notes/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

51A380 (1-23) Commonwealth of Kentucky DEPARTMENT OF REVENUE

DECLARATION OF DOMICILE FOR PURCHASE OF RESIDENTIAL UTILITIES

51A380 (1-23)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE