Application For Certificate Of Registration For Coal Severers And/or Processors Form - Commonwealth Of Kentucky Page 2
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1
255A001 (12-03)
Page 2
1. Check type of ownership:
o
o
o
Individual
Limited liability company (LLC)
Joint venture
o
o
Check which applies to the LLC
Partnership
Government
o
o
o
Limited partnership
Disregarded entity
Real estate investment trust
o
o
o
Limited liability partnership (LLP)
Member(s) taxed as
Association
o
o
_________________
Corporation
Other (Give brief description)
o
o
S corporation
Taxed as partnership
____________________________
o
Taxed as corporation
____________________________
o
Taxed as S corporation
____________________________
2. Print or type owner(s), member(s) or corporate officer(s) name(s), title, residence address and Social Security number(s).
(Use attachments, if necessary.)
Last Name
First Name
M.I.
Title
Residence Address
Social Security Number
( __ __ __ ) __ __ __ – __ __ __ __
Name of Person Preparing Application
Title
Telephone Number (Include Area Code)
Address
City
State
ZIP Code
➤ IMPORTANT: APPLICATION MUST BE SIGNED BELOW.
The above statements are hereby certified to be correct to the best knowledge and belief of the undersigned who is duly
authorized to sign this application. Signature of owner or all partners required. If a corporation, an officer must sign. (Attach
separate sheet if necessary.)
Signed ________________________________________
Signed ________________________________________
Title _______________________
Date ____________
Title ________________________
Date ___________
Signed ________________________________________
Signed ________________________________________
Title _______________________
Date ____________
Title ________________________
Date ___________
COAL SEVERANCE AND PROCESSING TAX
Every person engaged in severing and/or processing coal must file an application to obtain a Certificate of Registration with the
Kentucky Revenue Cabinet prior to severing and/or processing coal in Kentucky. Processing includes cleaning, breaking,
sizing, dust allaying, treating to prevent freezing or loading for shipment. This is limited to persons who own or have an
economic interest in the coal and does not include a contract miner . Also, persons who only receive an arm’s length
royalty are not considered as having an economic interest and are not required to register.
NOTE: Persons required to obtain a Certificate of Registration for the coal severance and processing tax must also
apply for a sales and use tax permit on the Kentucky Tax Registration Application, Form 10A100.
Mail completed application to Kentucky Revenue Cabinet, P.O. Box 1074, Frankfort, KY 40602-1074.
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