Form St-200 - Utility Sales Tax Exemption Application
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1
2Form ST-200
Utility Sales Tax Exemption Application
State Form 48843
For Purchase of Metered Utility or Telecommunication Services
(R/ 11-02)
Reverse Side Must Also Be Completed
A.
Mailing Address:
B.
Meter Location Address:
Legal Name:
DBA Name:
(doing business as)
Street / P.O. Box:
Street / P.O. Box:
City, State, Zip:
City, State, Zip:
(
)
(
)
Telephone Number:
Telephone Number:
C. Complete All Applicable Blanks:
1
Indiana Registered Retail Merchants Number
2
Indiana Not-For-Profit Registration Number (13 digits)
*
3
Social Security Number (farmers only)
4
Federal I.D. Number
5
Type of Energy/Utility Service
(telephone, gas, electric, steam or water)
6
Meter Number
7
Account Number
8
Name of Utility Company
9
Annual K.W.H. Cubic Feet or Gallons
*
(used in previous calendar year)
*
10
Average Monthly Bill
*
11
Total Hours of Operation Per Day
*
12
Number of Operational Days Per Week
*
13
Number of Operational Weeks Per Year
14
Billing Name
(a copy of the utility bill with billing name must be attached)
Not-For-Profit (NFP) Organizations and Governmental entities complete lines without the (*). On the reverse side, complete Summary
(Schedule D), sign and date.
For Department Use Only
Exempt %
Disposition
Date
Yes
No
NAICS Code
Issue ST-109
User ID
POA?
Yes
No
Representative
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Parent category: Financial