DECLARATION OF DOMICILE FOR RESIDENTIAL UTILITIES ONLINE FORM

Declaration of Domicile for Purchase of Residential Utilities for NOLIN RURAL ELECTRIC

This online form is for residential utilities provided by Nolin Rural Electric Cooperative only. Complete a separate form for each residential service address. In accordance with the provisions of KRS 139.470(7) this declaration may only be executed for the purchase of sewer services, water, and fuel by Kentucky residents for use in heating, water heating, cooking, lighting, and other residential uses. “Fuel” shall include but not be limited to natural gas, electricity, fuel oil, bottled gas, coal, coke, and wood.

Name of account holder(Required)

First Last

is accountholder for

Service address with a Nolin RECC account(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is this service address the primary domicile (residence) of the account holder?(Required)

YES

If this service address is NOT the primary domicile for the account holder, who resides at this service address? Please include first and last name.

First Last

Relationship of the resident to the account holder

Name of person signing this declaration (cannot be landlord)(Required)

First Last

Signature of resident or representative(Required)

I declare that the address listed is my place of domicile* or the place of domicile* of the resident I have listed here and the purchase of residential utilities for use at this address meets the qualifications for exemption from Kentucky sales and use tax under KRS 139.470(7). Accordingly, I request the account associated with the above listed service address be classified as exempt from sales and use tax. I understand the exemption will begin on the date of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative. Under penalties of perjury, I swear or affirm that the information on this declaration is true and correct as to every material matter.

Please provide a phone number where we can reach you if we have any questions(Required)

* KRS 139.470(7) describes a place of domicile as “the place where an individual has his or her legal, true, fixed and permanent home and principal establishment, and to which, whenever the individual is absent, the individual has the intention of returning.”
Instructions
• Submit the Declaration of Domicile to each applicable utility provider or rural electric cooperative, not to the Department of Revenue.
• Each resident may have only one place of domicile but may be listed as a responsible party for other service addresses.
• The change in taxability for accounts will be effective on the first day of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative.
Department of Revenue Contact Information:
Phone: 502-564-5170
Email: DOR.Webresponsesalestax@ky.gov

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