Application For Certificate Of Registration For Coal Severers And/or Processors Form - Commonwealth Of Kentucky
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255A001 (12-03)
APPLICATION FOR CERTIFICATE OF REGISTRATION
DO NOT USE THIS SPACE
FOR COAL SEVERERS AND/OR PROCESSORS
Commonwealth of Kentucky
REVENUE CABINET
For assistance with this application, call the Revenue Cabinet at (502) 564-3371.
See Instructions on Reverse
Answer all questions completely. Incomplete applications will be returned to you.
(Print or Type the Answers to Questions)
COMPLETE BUSINESS NAME AND LOCATION ADDRESS
MAILING ADDRESS (IF NOT SAME AS LOCATION ADDRESS)
Business Name
Business Name
Street Address or Route Number
Street Address or Post Office or Route Number
City
State
ZIP Code
City
State
ZIP Code
County
Telephone Number (Include Area Code)
County
Telephone Number (Include Area Code)
1. Federal Employer I.D. Number
7. Do you purchase coal solely for the purpose of resale with
no processing involved ?
o
o
__ __ – __ __ __ __ __ __ __
Yes
No
2. Do you mine coal that you own or possess the mineral rights
8. If the answer to question 2 under this section is yes, do
to either by deed, lease, consent, etc.?
you also operate as a contract miner, mining coal
belonging to others?
o
o
o
o
Yes
No
Yes
No
9. Are you entitled to the depletion allowance under
3. Do you employ others (contract miners) to mine your coal?
Section 611 of the Internal Revenue Code?
o
o
Yes
No
o
o
Yes
No
If no, who is entitled to the depletion allowance?
4. Do you operate as a contract miner, mining coal belonging
Name
to others?
o
o
Yes
No
Address
5. Do you operate a tipple or processing plant?
City
State
ZIP Code
o
o
Yes
No
10. Do you own or operate any other coal mining, coal
processing (tipple, etc.) or coal brokerage company?
o
o
6. Do you purchase coal for the purpose of processing
Yes
No
(cleaning, breaking, sizing, dust allaying, treating to
prevent freezing or loading for shipment) and resale?
11. Date mining or processing operation began or will begin
o
o
Yes
No
__ __ / __ __ / __ __
Mo.
Day
Yr.
List the mines that you operate in Kentucky. (Attach a continuation page, if necessary.)
Location of
Business
Surface Disturbance
Kentucky Department
MHSA
Location
Contract
Mining Permit
of Mines and
Identification
Mine Name
(County)
Miner Name
Number
Minerals File Number
Number
15–
15–
15–
Location of
Records
Street
City or Town
County
State
ZIP Code
Name and address of previous owner, if any
Previous
Owner
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