Form 51a112 - Application For Direct Pay Authorization printable pdf download

Form 51a112 - Application For Direct Pay Authorization

APPLICATION FOR

51A112 (12-09)

Commonwealth of Kentucky

DIRECT PAY AUTHORIZATION

DEPARTMENT OF REVENUE

Enter Legal Business Name

Federal Employer Identiﬁ cation Number

__ __ – __ __ __ __ __ __ __

Name of

Applicant

Date Operations Began in Kentucky

Kentucky

Business

Location

Number and Street

City

County

State

ZIP Code

Mailing

Address

P.O. Box or Number and Street

City

County

State

ZIP Code

Type of

Operation

Manufacturing/Processing

Mining/Quarrying

Transportation Company

Distribution Facility

Account Number

(

)

Kentucky Employer's Withholding

Fax Number

Kentucky Corporation Income and License

(

)

Kentucky Sales and Use

Telephone Number

E-mail Address

1. Are you engaged in business and have property (other than ofﬁ ce furniture and equipment) located in more

than one state?

Yes

Location of Home Ofﬁ ce

Location of all plants or places of business (attach separate sheet, if necessary)

Other

Amount of tangible personal property or digital property purchased for use in your Kentucky business

Information

operations in the last calendar or ﬁ scal year.

Year Ending

Amount

Are your records maintained in such a manner that the amount of tangible personal property or digital

property purchased from a Kentucky vendor may be properly reported?

Yes

Are records maintained in such a manner that the amount of tangible personal property or digital property

purchased from a vendor out of state, stored, used or otherwise consumed in Kentucky and elsewhere can be

veriﬁ ed?

Yes

Attach a detailed description of the documentation maintained that reﬂ ects the proper amount of taxable

purchases.

Do you have a record of timely payment of all taxes administered by the Kentucky Department of Revenue?

Yes

Have you included your most recent certiﬁ ed ﬁ nancial statement with this application?

Yes

I hereby certify that the above statements are correct to the best of my knowledge and belief and that I am duly authorized to sign this application. I agree

that, in consideration for issuance of this Direct Pay Authorization, I will directly report and pay to the Department of Revenue, the sales or use tax that

would have been remitted to the department by my supplier and myself had this Direct Pay Authorization not been issued.

Signature

Title

Date

Print Name