Form Kwh 3 - Application For Self-Assessing Purchaser
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1
2KWH 3
Rev. 11/08
Reset Form
P.O. Box 530
Columbus, OH 43216-0530
Phone (614) 466-7026 • Fax (614) 728-1806
Application for Self-Assessing Purchaser
for the registration year May 1, 20
to April 20, 20
Name
FEIN
Address
Mailing address (if different from above)
Contact person
Telephone number
Fax number
E-mail address
1. Physical location of self-assessing purchaser (attach diagram or description if the location is serviced by multiple meters
or if one meter services multiple locations)
Street address
City
State
ZIP code
2. Name of electric distribution company servicing location
3. Meter numbers used by electric distribution company for billing purposes
4. Your account number assigned by electric distribution company
5. Number of kilowatt hours consumed at this location in previous calendar year
6. If line 5 is less than 45 million, estimated annual consumption
At the time of making the application, and by the fi rst day of May of each year, a self-assessing purchaser shall pay a fee of
fi ve hundred dollars ($500) payable to the Ohio Treasurer of State to be submitted along with the application to the Ohio
Department of Taxation, P.O. Box 530, Columbus, OH 43216-0530. This registration, if approved, will remain in effect through
April 30 of the registration year or until canceled by the registrant or revoked by the tax commissioner.
Signature
Title
Date
I declare under penalties of perjury that the above statements have been examined by me and to the best of my knowledge
and belief are true, complete and correct.
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