Form 51a401 - Governmental Public Facility Application For Sales Tax Rebate

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51A401 (6-10)
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
GOVERNMENTAL PUBLIC FACILITY
APPLICATION FOR SALES TAX REBATE
Name of Governmental Entity (please print or type)
Name of Public Facility
Name
Public Facility
Location Address
Number and Street
City
County
State
ZIP Code
Mailing
Address
(if different)
Number and Street
City
County
State
ZIP Code
(1) What is the governmental entity’s effective date of qualifi cation for the sales tax rebate? _____________________________________
(2) Total amount of tax rebate requested $ _________________________
(Per KRS 139.533(2)(c), the total tax rebate shall not exceed $250,000 in each calendar year.)
(3) Please list account information below for sales of admissions or tangible personal property included in the rebate request:
Vendor Name
SU #
Tax Periods
Tax Amount
*Per KRS 139.533(4), a qualifi ed applicant shall fi le a request within 60 days following the end of each calendar quarter. A Vendor
Agreement (Form 51A402) must be completed for each third party vendor listed above.
(4) Was compensation claimed when tax was remitted to state?
Yes
No
(5) Banking information (if electronic fund transfer requested).
Name of Bank ___________________________________________________
Depositor Account Number (DAN) __________________________________
Routing Transit Number (RTN) _____________________________________
Account Type:
Checking
Savings
Other
I, the undersigned, declare under the penalties of perjury that I have examined this application (including any attached schedules, or statements)
and to the best of my knowledge and belief, the statements contained herein are true, complete and correct, and that I am duly authorized to
sign this application. It is understood that the books and records supporting this rebate application must be maintained for a period of four
years from the date the rebate is issued and are subject to audit at the discretion of the Department of Revenue. I, the undersigned, consent and
agree that any excess amount refunded pursuant to this application shall be recovered within four years from the date the rebate is issued. The
undersigned certifi es that no tax liability of any kind is due or owing the Commonwealth of Kentucky by this applicant.
Contact Information:
Name
: _____________________________________
Title: ________________________________________
(please print or type)
Phone: ___________________________________________________
E-mail: ______________________________________
Signed: __________________________________________________
Date: ________________________________________
Return to Department of Revenue, Division of Sales and Use Tax, P.O. Box 181, Frankfort, Kentucky, 40602-0181

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