Form St-21pec - Sales And Use Tax Refund Application For Use By Pec Entities printable pdf download

KANSAS

SALES AND USE TAX REFUND APPLICATION FOR USE BY PEC ENTITIES

PART A – PEC ENTITY INFORMATION

Note: A “PEC Entity” is an entity such as a political subdivision, school, church, or zoo that qualifies for exemption under

K.S.A. 79-3606(d), (e), (xx), (aaa), or (ccc).

*Employer Identification Number or Social Security Number

*Name

____ ____ ____ ____ ____ ____ ____ ____ ____

*Exempt Entity Number

*Address

K S

____ ____ ____ ____ ____ ____ ____ ____

(To secure a refund you must provide the exempt entity exemption

*City, State, Zip Code

number that was issued to you by the department. If you do not

have one, you must apply to the department and secure a number

before your refund request can be processed.)

*Contact Person

Telephone Number

E-Mail Address

Fax Number

* Denotes required fields for completion

1. Check the appropriate PEC exemption:

‰

Hospital, School, Political Subdivision Project, K.S.A. 79-3606(d)

U.S. Government Project, K.S.A. 79-3606(e)

‰

Nonprofit Zoo, K.S.A. 79-3606(xx)

Religious Organizations, K.S.A. 79-3606(aaa)

‰

Primary Care Clinic or Health Center, K.S.A. 79-3606(ccc)

Other (Please explain) ________________________

PART B – DESCRIPTION OF PROJECT

2. Project Location: _______________________________________________________________________________

Street and City

3. Nature of Project: ______________________________________________________________________________

(Roof repair, bathroom remodel, building addition, etc.)

4. Name of General Contractor: _____________________________________________________________________

5. Approximate Begin and End Dates of the Project: ______________________________________________________

6. Approximate Project Cost to the PEC Entity: $ _____________________

7. Did the Kansas Department of Revenue issue a Project Exemption Certificate that covered part of the project?

‰

Yes If yes, please state the project exemption number on the certificate: ____________________________

PART C – AFFIDAVIT OF OFFICER OR OFFICIAL SUBMITTING THIS REFUND APPLICATION

AFFIDAVIT

I certify under penalties of perjury that, to the best of my knowledge, all of the information and statements made in this Refund

Application are true and correct.

__________________________________________________________________

________________________

Affiant’s Signature

Date

STATE OF KANSAS

)

SS:

)

COUNTY OF

________________________________

)

This PEC Refund Application was acknowledged before me on __________________________________ , 20 _____ by

_____________________________________________________ as _____________________________________ .

Name of Affiant

Official Capacity (officer, superintendent, business manager, etc.)

Notary Public: ________________________________

My appointment expires: _______________________________

ST-21PEC (Rev. 7/12)

Form St-21pec - Sales And Use Tax Refund Application For Use By Pec Entities

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