Form E-416 - Claim For Low-Income Electricity Customer Sales Tax Exemption
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1SALES & USE TAX SECTION
STATE OF ARKANSAS
P. O. BOX 1272
Department of Finance
LITTLE ROCK, AR 72203-1272
and Administration
PHONE (501) 682-1895
FAX (501) 682-7904
sales.tax@rev.state.ar.us
CLAIM FOR LOW-INCOME ELECTRICITY CUSTOMER SALES TAX EXEMPTION
____________________________________________________
______________________________________________
Claimant’s Name & Social Security Number
Electric Service Account Number
____________________________________________
Spouse’s Name & Social Security Number
_____________________________________________________________________________________________________
Street Address / P.O. Box
Apt. No. or Rural Address
City
State
Zip Code
Please itemize below all household income for previous calendar year 20____.
Income of
Income of
Claimant
Spouse
a. * Social Security Payments of all types
b. * Veterans’ pensions and disability payments
c.
Salaries or income from farm or self-employment
d. * Railroad retirement benefits
e.
Interest income
f.
Dividends
g.
Rent and royalties income
h.
Income from sale of realty, stocks, bonds
i. * Arkansas Teachers, Public Employees, State Employees, State
Police and Highway Department Employees retirement
benefits or pension
j. * Federal retirement and pensions
k. Cash public assistance and relief (SSI, etc.)
l. Miscellaneous Income (Alimony, support money, workers’
compensation, loss of time insurance, or any other pension/annuity
* These sources are not reportable for World War 1 Veterans or their
widows
Totals
Total of Both Incomes
(If your total household income exceeds $12,000.00, you are not eligible to file this claim. If you are eligible for
this exemption, you are exempt only on the tax on the first 500 kilowatt hours per month. A.C.A §26-52-416)
I certify, under penalties of false swearing, that the above information is true and complete and I hereby claim the
sales tax exemption provided by Act 120 of 1983.
Claimant’s Signature
Date
Important Note: This claim form is subject to audit, for tax purposes, by the Dept. of Finance and Administration.
RETURN THIS FORM TO YOUR ELECTRIC COMPANY
Form E-416
R 01/2008
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