Form St-200 - Utility Sales Tax Exemption Application
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3Utility Sales Tax Exemption Application
Form ST-200
State Form 48843
For Purchase of Metered Utility or Telecommunication Services
(R4 / 1-13)
Reverse Side Must Also Be Completed
A. Mailing Address
B. Meter Location Address
Legal Name:
DBA (doing business as) Name:
Street/P.O. Box:
Street/P.O. Box:
City, State, Zip:
City, State, Zip:
Telephone Number:
Telephone Number:
C. Fill In All Applicable Blanks
Nonprofit organizations and governmental entities should complete lines without the (). On the reverse side, complete
the Summary (Schedule D) and sign and date the form.
1 Indiana Registered Retail Merchants Number
2 Indiana Nonprofit Registration Number (13 digits)
3 Social Security Number (farmers only)
4 Federal ID Number
Type of Energy/Utility Service
(telephone, gas, electric, steam, or water)
5
6 Meter Number
7 Account Number
8 Name of Utility Company
Annual K.W.H. Cubic Feet or Gallons
9
(used in previous calendar year)
10 Average Monthly Bill
11 Total Hours of Operation Per Day
12 Number of Operational Days Per Week
13 Number of Operational Weeks Per Year
Billing Name (a copy of the utility bill with billing name
14
must be attached)
For Department Use Only
Disposition
Exempt %
Date
□
□
Issue ST-109
Yes
No
NAICS Code
User ID
□
□
Representative
POA
Yes
No
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Parent category: Financial