Form 31-116a - Energy Used For Fully Taxable Purposes

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Iowa Department of Revenue
Energy Used for Fully Taxable Purposes
This is not a claim for refund form.
This form is to be completed by the
purchaser and provided to the seller.
This form is to be completed by an energy
Seller: Keep this in your files
purchaser that will use energy in a manner
which does not qualify for phase out of Iowa
Purchaser: Keep a copy for your records
Sales Tax.
Purchaser
Seller Name
Address
Address
City
State
ZIP
City
State
ZIP
SS#/Fed ID #
Phone #
General Nature of Business
FUEL PURCHASED:
Electricity
Gas
Other, specify ________________
FULLY TAXABLE ENERGY IS USED FOR (SPECIFY): __________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PERCENTAGE USED NOT QUALIFYING FOR PHASE OUT OF IOWA SALES TAX: _________________ %
(from line 3 on reverse side of this form)
Meter No. ______________________________________________________________________
Utility Account No. _______________________________________________________________
If fuel is not metered, explain method of purchase and storage.
Documentation must be attached to or be part of this certificate in order for a seller to accept the certificate. The documentation
must be specific when listing taxable uses. If information necessary to determine taxable percentage is not provided, additional
information must be requested.
Under penalties of perjury, I swear or affirm that the information on and attached to this form is true and correct as to every
material matter.
Authorized Signature of Owner, Partner or Corporate Officer: ______________________________________________
Title: _______________________________________________ Date: _____________________
For more information, visit our Tax Research Library
Please reference Rules 701-15.3 and 231.16
31-116a (08/16/11)

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