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STATEMENT FOR SALES TAX EXEMPTION ON ELECTRICITY, GAS,

OR WATER FURNISHED THROUGH ONE METER

Please type or print this form and send a completed copy WITH worksheets to your utility company.

Complete a form for each meter on which you are applying for an exemption.

Address of meter location

Utility account number

In accordance with the Kansas Retailers’ Sales Tax Act, the undersigned purchaser states that the (circle one: electricity, gas, or water)

sold and furnished by (name of utility company)

through

meter number

at the above location is used for the following purposes based on annual consumption.

uses electricity, gas, or water for the following purpose (check one):

PURCHASER (Name of individual, company or organization)

Unless otherwise indicated, the uses below are exempt from state and local sales tax.

Agricultural use.

Government entity.

(Subject to local sales tax)

Certain nonprofit corporations exempt from real estate

Ingredient or component part.

property tax—i.e., adult care homes (nursing homes); private

Irrigation of crops.

children's homes (nursing home foster care, etc.); housing

Movement in interstate commerce by railroad or public utility.

for low and limited income elderly and disabled persons

Noncommercial educational radio or TV station.

(includes HUD housing projects); housing for the elderly;

Noncommercial residential use.

(Subject to local sales tax)

and group housing for mentally ill, retarded, and other

Nonprofit hospital.

disabled persons.

Nonprofit museum or historical society.

TTACH A COPY OF THE

ORDER

FROM THE BOARD

Nonprofit zoo.

OF TAX APPEALS

Consumed in the production, manufacturing, processing,

Over-the-air free access radio or TV station. Only the

mining, drilling, refining, or compounding of tangible

electricity used to produce the broadcast signal is exempt.

personal property, or the treatment of by-products or wastes

All other utility use is taxable.

of any above processes.

Providing taxable services.

Educational institutions and nonprofit trusts, nonprofit

Religious organization exempt from federal taxation under

endowment associations and foundations operated for the

section 501(c)(3) of the federal Internal Revenue Code.

sole benefit of an education institution.

Severing of oil.

Describe the taxable service; movement in interstate commerce; agricultural use; or property produced, manufactured, etc.

NOTE: All electricity, gas, or water used to light, heat, cool, clean or maintain equipment, buildings or business facilities (offices,

plants, shops, warehouses) are FULLY TAXABLE. This includes but is not limited to, electricity, gas, or water for air conditioners, all

lighting (including production area), exhaust fans, freezers, heaters, refrigerators, other appliances and machines.

EXEMPT PERCENT

% (See instructions)

The undersigned purchaser agrees and certifies that (a) this statement is true, correct, and complete; (b) the worksheets used to determine the

"Exempt Percent" will be kept by the undersigned and copies of the worksheets and this completed form will be provided to the utility

company and the Department of Revenue and (c) in the event there is a change in the "Exempt Percent," a revised statement will be filed

immediately with the utility company and the Kansas Department of Revenue. If the electricity, gas, or water exempted from taxation is determined

to be taxable at a rate other than stated above, the undersigned purchaser agrees to reimburse the utility company or the Kansas Department of

Revenue for any amounts assessed as retailers' sales or compensating tax, penalties, and/or interest.

Purchaser:

Phone No.

(

)

Individual, company, or organization name

Purchaser’s mailing address:

Street, RR or P.O. Box

City

State

Zip + 4

Authorized signature:

Date:

If retail business, Kansas sales tax registration number

Type of business

ST-28B (Rev. 2/00)

Form St-28b - Statement For Sales Tax Exemption On Electricity, Gas, Or Water Furnished Through One Meter - State Of Kansas

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