Form 31-116b - Energy Used For Taxable Purposes printable pdf download

Form 31-116b - Energy Used For Taxable Purposes

Iowa Department of Revenue

Energy Used for 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 purchaser that will use energy in a manner which does

not qualify for the residential energy exemption from Iowa sales tax.

Seller: Keep this in your files.

Purchaser: Keep a copy for your records.

Purchaser

Seller Name

Address

City, State, ZIP

General Nature of Business

Daytime Telephone Number

FUEL PURCHASED:

Electricity

Gas

Other, specify ________________

TAXABLE ENERGY IS USED FOR (SPECIFY): ________________________________________________

______________________________________________________________________________________

Percentage used not qualifying for the residential energy exemption from Iowa sales tax: _____________ %

(from line 3 on reverse side of this form)

Meter No. ______________________________________________________________________

Utility Account No. _______________________________________________________________

If fuel is not metered, attach explanation of the method of purchase and storage.

Supporting Documentation:

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.

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: __________________

31-116a (09/21/12)

Form 31-116b - Energy Used For Taxable Purposes