Form Pub. Ks-1560 - Kansas Business Taxes For Schools & Educational Institutions Page 30

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REQUEST FOR PROJECT EXEMPTION CERTIFICATE
Kansas Department of Revenue
Date
Office of Policy and Research
915 SW Harrison St., Room 230
Telephone: (785) 296-3081
Topeka, Kansas 66612-1588
FAX: (785) 296-7928
It is requested that a Certificate of Exemption be issued to the Petitioning Authority for the following described project if it is
determined by the Department of Revenue that the proposed project qualifies for exemption from sales tax under the provisions of
K.S.A. 79-3606(d) - public or private nonprofit hospital, elementary or secondary school, educational institution & political
subdivisions of the state of Kansas; K.S.A. 79-3606(e) - United States Government, it agencies or instrumentalities; K.S.A. 79­
3606(xx) - 501(c)(3) nonprofit zoo; K.S.A. 79-3606(aaa) - 501(c)(3) religious organization; K.S.A. 79-3606(ccc) - 501(c)(3) primary
care clinic; K.S.A. 79-3606 (iii) non-profit food distribution center; K.S.A. 79-3606 (qqq) TLC for children and families, inc.; K.S.A.
79-3606 (sss) non-profit charitable family providers; K.S.A. 79-3606 (ttt) museum within a designated qualified hometown or
K.S.A.(uuu) Kansas children's Service League.
(A) Type of project:
Describe Work to be Done
A. Present use of facility:
B. Proposed use of facility after project:
(B)
P roject location:
Building Number, Street Address, City, State, and Zip
(C) Is this project being constructed as part of a business enterprise whose sales are subject to sales tax (e.g., municipal water,
electric or gas companies)?
Yes
No
(D) Is the Petitioning Authority authorized to levy ad valorem taxes on tangible property?
Yes
No
If so, under what statute?
(E) A. Is this project being totally financed by industrial revenue bonds?
Yes
No
B. Is this project being partially financed by industrial revenue bonds?
Yes
No
Amount of bonds being issued for project:
If you answered "Yes" to A or B, you must complete the agreement on the back of this form and attach a copy of the letter of
intent or resolution of intent to issue bonds.
If you answered "No" to A and B, how is the project being financed (explain type of tax, bonds, etc.)?
(F)
Name of claimant owner of project:
(G)
Starting date:
(H)
Estimated completion date:
(I)
Estimated project cost:
(J)
List names and addresses of prime contractors:
(K)
Contract date:
(L)
Contract number:
(M) Project number:
Petitioning Authority
Mailing Address
Signature of Authorized Representative
City, State & Zip Code
Type or Print Name
Tax Exempt Entity No.
Title
Phone Number
PR-76 (Rev. 07/06)

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