Form Khw-3 - Application For Self-Assessing Purchaser printable pdf download

KHW-3

Rev. 2/04

P.O. Box 530hColumbus, OH 43216-0530

Telephone: (614) 466-7026hFax: (614) 752-8644

Application for Self-Assessing Purchaser

for the registration year May 1, 20_____ to April 30, 20_____

Name _____________________________________________________ FEIN________________________________

Address _________________________________________________________________________________________

________________________________________________________________________________________________

Mailing address (if different from above) ________________________________________________________________

________________________________________________________________________________________________

Contact person ____________________________________ Telephone number _______________________________

Fax number _______________________________ E-mail address __________________________________________

1. Physical location of self-assessing purchaser (attach diagram or description if the location is serviced by multiple

meters or if one meter services multiple locations)

_____________________________________________________________________________________________

Street address

City

State

ZIP code

Name of electric distribution company servicing location ________________________________________________

Meter numbers used by electric distribution company for billing purposes___________________________________

_____________________________________________________________________________________________

Your account number assigned by electric distribution company __________________________________________

Number of kilowatt hours consumed at this location in previous calendar year _______________________________

If line 5 is less than 45 million, estimated annual consumption ___________________________________________

At the time of making the application, and by the first day of May of each year, a self-assessing purchaser shall pay a fee

of five hundred dollars ($500) payable to the Treasurer of State to be submitted along with the application to the Ohio

Department of Taxation, P.O. Box 530, Columbus, OH 43216-0530. This registration, if approved, will remain in effect

through April 30 of the registration year or until canceled by the registrant or revoked by the Tax Commissioner.

Signature_________________________________ Title____________________________ Date____________________

I declare under penalties of perjury that the above statements have been examined by me and to the best of my

knowledge and belief are true, complete and correct.

Form Khw-3 - Application For Self-Assessing Purchaser