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Form 1749 - Application For Electrical Energy Direct Pay Authorization And Basic Steelmaking Exemption Page 2

PAGE 2

12. LOCATION OF ELECTRICAL ENERGY USE

STREET ADDRESS (DO NOT USE P .O. BOX NUMBER OR RURAL ROUTE)

COUNTY

CODE

CITY

CODE

STATE

ZIP CODE

13. NAME AND ADDRESS OF ELECTRICAL ENERGY SUPPLIER

SUPPLIER’S NAME

STREET ADDRESS

CITY

STATE

ZIP CODE

14. APPLICABLE NUMBERS ASSIGNED BY SUPPLIER (ATTACH SUPPLEMENTAL LIST IF NECESSARY)

15. TOTAL COST OF ELECTRICAL ENERGY USED IN OPERATION OF BUSINESS FOR CALENDAR YEAR

16. TOTAL COST OF PRODUCING PRODUCT DESCRIBED IN LINE 10 FOR CALENDAR YEAR

17. TOTAL COST OF ELECTRICAL ENERGY DIRECTLY USED IN PRODUCING PRODUCT DESCRIBED IN LINE 10 FOR CALENDAR YEAR

18. ADJUSTED TOTAL COST OF PRODUCTION FOR CALENDAR YEAR

(LINE 16 LESS LINE 17):

19. ADDITIONAL SPACE FOR CONTINUATION OF ANY PREVIOUS LINES (INDICATE LINE NUMBER) OR FOR PROVIDING ADDITIONAL INFORMA -

TION YOU FEEL IS RELEVANT TO THIS APPLICATION.

20. SIGNATURE

UNDER PENALTIES OF PERJURY , I DECLARE THAT I HAVE DIRECT CONTROL, SUPERVISION OR RESPONSIBILITY FOR COMPLETING THIS

APPLICATION.

SIGNATURE

TITLE

DATE

FOR DEPARTMENT USE ONLY - DO NOT WRITE BELOW THIS LINE

FIELD AUDIT

BUSINESS TAX

Recommend Approval

Recommend Denial

Recommend Approval

Recommend Denial

Comments:

SIGNATURE

DATE

SIGNATURE

DATE

MO 860-0919 (12-99)

DOR-1749 (12-99)

Form 1749 - Application For Electrical Energy Direct Pay Authorization And Basic Steelmaking Exemption Page 2