Form Pr-76 - Request For Project Exemption Certificate
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1
2REQUEST FOR PROJECT EXEMPTION CERTIFICATE
Kansas Department of Revenue
Date________________________
Office of Policy and Research
915 SW Harrison St., Room 230
Telephone: (785) 296-3081
Topeka, KS 66612-1588
Fax: (785) 296-7928
It is requested that a Certificate of Exemption be issued to the Petitioning Authority for the following described project if it is
determined by the Department of Revenue that the proposed project qualifies for exemption from sales tax under the provisions
of K.S.A. 79-3606(d) – public or private nonprofit hospital, elementary or secondary school, educational institution & political
subdivisions of the state of Kansas; K.S.A. 79-3606(e) – United States Government, its agencies or instrumentalities; K.S.A.
79-3606(xx) – 501(c)(3) nonprofit zoo; K.S.A. 79-3606(aaa) – 501(c)(3) religious organization; K.S.A. 79-3606(ccc) – 501(c)(3)
primary care clinic; K.S.A. 79-3606 (iii) non-profit food distribution center; K.S.A. 79-3606 (qqq) TLC for Children and Families,
Inc.; K.S.A. 79-3606 (sss) non-profit charitable family providers; K.S.A. 79-3606 (ttt) museum within a designated qualified
hometown or K.S.A.(uuu) Kansas Children’s Service League.
(A)
Type of project: ______________________________________________________________________________
Describe work to be done
A. Present use of facility: ______________________________________________________________________
B. Proposed use of facility after project: ___________________________________________________________
(B)
Project location: ______________________________________________________________________________
Building Number, Street Address, City, State, and Zip Code
(C) Is this project being constructed as part of a business enterprise whose sales are subject to sales tax (e.g., municipal
‰
‰
water, electric or gas companies)?
Yes
No
‰
‰
(D) Is the Petitioning Authority authorized to levy ad valorem taxes on tangible property?
Yes
No
‰
‰
(E)
A. Is this project being totally financed by industrial revenue bonds?
Yes
No
‰
‰
B. Is this project being partially financed by industrial revenue bonds?
Yes
No
Amount of bonds being issued for project: _________________________________________________________
If you answered “Yes” to A or B, you must complete the agreement on the back of this form and attach a copy of the
letter of intent or resolution of intent to issue bonds.
If you answered “No” to A or B, how is the project being financed (explain type of tax, bonds, etc.)?
___________________________________________________________________________________________
(F)
Name of claimant owner of project: _______________________________________________________________
(G) Starting date: ___________________________
(H)
Estimated completion date: _________________
( I )
Estimated project cost: ___________________
(J)
List names and addresses of prime contractors:
(K)
Contract date: __________________________
(L)
Contract number: ________________________
(M) Project number: _________________________
______________________________________________
____________________________________________
Petitioning Authority
Mailing Address
______________________________________________
____________________________________________
Signature of Authorized Representative
City, State & Zip Code
______________________________________________
_________________________
________________
Type or Print Name
Tax Exempt Entity No.
Title
Phone Number
PR-76 (Rev. 7/06)
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