Form 1749 E-25 - Application For 25 Percent Recovered Material Electrical Energy Exemption For Manufacturing - 2016 Page 3

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Missouri Tax I.D. Number
List all raw material suppliers and percentage of recovered material content necessary to qualify for the exemption.
A
B
C
D
E
Description of
Total Weight or
% of Recovered
(B*C) Weight or
% Recovered
Name of Raw Material Supplier
Raw Material
Volume (1)
Material (2)
Volume of
Materials in Total
Recovered Materials
Raw Materials (3)
Total
%
Check Figure: Total of Column D divided by Column B
Check Figure
%
(This number should equal the total for Column E.)
(1) You can use either the weight of the materials or the volume of the materials. In either case, you must use the same unit of measure
(pounds, ounces, feet or inches).
(2) This represents the percent of recovered materials in the raw materials. Your supplier should provide you with this information on form 5021.
(3) Divide amounts in Column D by the total of Column B.
Attach additional list if needed.
If at any time you no longer qualify for this exemption, it is your responsibility to notify
your utility supplier, withdraw your exemption, and remit the appropriate tax to the state.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I declare that I
have direct control, supervision or responsibility for completing this application. Declaration of preparer (other than taxpayer) is based on all
information of which he or she has any knowledge. As provided in
Chapter 143,
RSMo, a penalty of up to $500 shall be imposed on any
individual who files a frivolous return.
Signature
Title
Printed Name
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form-1749E-25 (Revised 08-2016)
Mail to: Taxation Division
Phone: (573) 751-2836
P.O. Box 358
Fax: (573) 522-1271
Visit
dor.mo.gov/business/sales/
Jefferson City, MO 65105-0358
E-mail:
salestaxexemptions@dor.mo.gov
for additional information.
*14016030001*
14016030001

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