Form Wp-4 - Irrevocable Election To Pay The Clean Drinking Water Fee

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NOTICE TO KANSAS DEPARTMENT OF REVENUE
IRREVOCABLE ELECTION TO PAY THE CLEAN DRINKING WATER FEE
The _________________________________
(Name of Public Water Supply System
(Water Protection Fee Registration Number)
(Kansas Sales Tax Registration Number)
irrevocably elects pursuant to 2004 Senate Bill 147, Section 11 to pay the Clean
Drinking Water Fee on retail sales of water beginning
January 1; April 1; July 1; or October 1 (check one) of ______ (enter year).
By making said election, the public water supply system understands that, as of the
date circled above, it will be exempt from all applicable Kansas Retailers' Sales or
Compensating Use taxes on its direct and indirect purchases of tangible personal
property and services used in the construction activities, operation or maintenance of
the district.
This election shall become effective on the above date only if the Department of
Revenue has received this document at least 30 days prior to such date.
(Signature of Authorized Individual)
(Date)
(Title)
(Printed Name)
(Phone Number)
MAIL OR FAX TO:
Miscellaneous Tax
Kansas Dept. of Revenue
915 SW Harrison St.
Topeka, KS 66612-1588
Phone: 785-368-8222
Fax: 785-291-3968
WP-4
(Rev. 6/13)

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