Sales Tax Exemption Form Email(Required) This Exemption Form is for:(Required) Primary Residence Exemption Landlord of Master Metered Property Only Primary Residence Exemption FormDECLARATION 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.Name of Account Holder First Last Service Address Street Address Address Line 2 City ZIP / Postal Code In relation to the above listed Serivce Address, I am: Resident Other If you are not the Resident of the above Service Address, please indicate the nature of your relationship.I declare that the address listed is my place of domicile* or the place of domicile* of 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.Signature of resident or representative First Last Date MM slash DD slash YYYY * 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 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.govLandlord of Master Metered Property OnlyMULTI-UNIT DECLARATION OF DOMICILE FOR LANDLORDS OR OTHER ACCOUNT HOLDERS OF MULTI-UNIT DWELLINGS SERVED BY A SINGLE METER (MASTER METER)Number of DeclarationsUnder penalties of perjury, I swear or affirm that the above number of declarations I am submitting with this form include 100% of the dwelling units at the service address below.Address Street Address Address Line 2 City ZIP / Postal Code Number of Dwelling UnitsAccount Name Authorized Signature First Last Date MM slash DD slash YYYY Instructions This Multi-Unit Declaration of Domicile is for landlords or other persons holding a single account with a utility provider or rural electric cooperative which serves multiple dwelling units. Submit the Multi-Unit Declaration of Domicile along with individual declarations for all dwelling units to each applicable utility provider or rural electric cooperative, not to the Department of Revenue. Landlords or other accountholders should submit a Multi-Unit Declaration of Domicile for each meter that serves multiple units; however, every unit served by the meter must have a fully-completed Declaration of Domicile for the account to qualify as residential. Landlords or other accountholders may not complete the Declaration of Domicile on behalf of their residents. Accounts for meters that exclusively serve common areas or that serve common areas and multiple dwelling units are not eligible for residential treatment. No declaration shall be submitted for these accounts. 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 Multi-Unit Declaration of Domicile by the utility provider or rural electric cooperative. Department of Revenue Contact Information: Phone: 502-564-5170 Email: DOR.Webresponsesalestax@ky.govPhoneThis field is for validation purposes and should be left unchanged.