Please enable JavaScript in your browser to complete this form.51A380 (1-23) Commonwealth of Kentucky DEPARTMENT OF REVENUE Select the UPG Location Nearest You: *Big 3 Propane, ShelbyvilleCalloway County Propane, MurrayCentral Kentucky Propane, MorgantownEastern Kentucky Propane, LilyGasper River Propane, AuburnGraves County Propane, MayfieldGreen River Propane, LivermoreGreenwell Propane, TaylorsvilleKen-Tenn Propane, ClintonLake Region Propane, HardinLittle River Propane, HopkinsvilleMammoth Propane, GlasgowMidway Propane, ClarksonNorthern Kentucky Propane, CynthianaPennyrile Propane, Dawson SpringsPrice's Ballard Carlisle Propane, LaCenterRiver Region Propane, MarionSouth Kentucky Propane, SomersetSuper Flame Propane, Dry RidgeSure Flame Propane, SpringfieldWest Kentucky Propane, PaducahDECLARATION 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 *FirstLastAccount Number *Email *Phone *Service Address *Address Line 1CityKentuckyAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSERVICE 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, *FirstLastam 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)FirstLastand 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 following1. 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 NameDate / Time of Form SubmissionDateTimeNotes/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 Submit
