Form 1749 E-10 - Application For 10 Percent Electrical Energy Exemption For Manufacturing - Missouri Department Of Revenue

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Missouri Department of Revenue
Department Use Only
Application for 10 Percent Electrical Energy
Form
(MM/DD/YY)
Exemption for Manufacturing
1749 E-10
Missouri Tax I.D.
Federal Employer
Number
I.D. Number
Note: This is not a refund application. A refund application must be filed by the utility in order to receive a refund for periods prior to issuance of
the direct pay authorization letter.
Complete this application to apply for electrical energy direct pay authorization if your electrical energy costs exceed 10 percent of total production cost
according to
Section 144.030.2(13),
RSMo. A separate application should be completed for each calendar year for which you are applying. If approved
and authorized, a non-expiring direct pay certificate will be issued. You do not need to reapply each year. 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. If you qualify at a later
date you can re-apply at that time.
1. Application Year and Identification Numbers
A
pplication Year (Calendar Year Only)
Type of Application
r
r
New
Renewal
2. Applicable Business Location
Business Trade Name
Business Phone
County
(__ __ __)__ __ __
__ __ __ __
Street Address (Do Not Use P.O. Box or Rural Route)
City
State
Zip Code
3. Owner Name and Address
Business Trade Name
County
Street Address (Do Not Use P.O. Box Or Rural Route)
City
State
Zip Code
4. Mailing Address (Select One)
County
r
r
r
Business Address
Owner Address
Other (Give Full Address Below)
Street Address
City
State
Zip Code
5. Contact Person (Attach Power of Attorney,
Form 2827
if not employed by applicant).
Name
Title
Phone
(__ __ __)__ __ __
__ __ __ __
6. Type of Exempt Electrical Energy Usage (Select One)
r
If you are claiming an exemption for more than one process, you must submit an application for each.
Material Recovery Processing Plant
r
r
r
r
r
r
r
Primary:
Compounding
Processing
Manufacturing
Mining
Producing
Secondary:
Fabricating
Processing
7. Description of Business Operations and Products Produced (Attach additional sheet if needed)
8. Name and Address of Electrical Energy Supplier
Supplier’s Name
County
Street Address
City
State
Zip Code
9. Applicable Numbers Assigned by Supplier (Attach additional sheet if needed)
Account Number(s)
Percentage Taxable
Percentage Exempt
Description of Electrical Usage
Form-1749E-10 (Revised 12-2015)
*14015010001*
14015010001

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