RVF-16024    Internet (09/21) 
 
                          TENNESSEE DEPARTMENT OF REVENUE 
                                Certified Distribution Sales Election 
                                 Franchise and Excise Tax      
 
 1. Taxpayer Name                                        Account Number                                      
 
 2. Mailing Address                                                                                          
                          Street                   City                       State         Zip Code 
 
 3. Business Contact                                                                                         
                          Name                   Phone Number                 Email Address 
 
 4. Effective date of election                   
                                                 Beginning date of tax period 
 
 5. Gross sales threshold $                       
 
 6. Receipts factor threshold                    % 
 
 Certified statements from distributors must be attached. 
 
                                 Taxpayer Affidavit 
 
 Under penalties of perjury, I declare that to the best of my knowledge this information is true 
 and correct and the gross sales threshold, receipts factor threshold, and all other requirements 
 of  Tenn.  Code  Ann.  §  67-4-2023  have  been  met.  I  understand  that  the  requirements  for  this 
 election must be met each year that its provisions are applied and that certified statements from 
 distributors must be maintained for each tax period this election is in effect.  The information 
 contained in this application is subject to audit by the Department of Revenue and may result in 
 the assessment of additional taxes, penalties, and interest if the statutory requirements for the 
 franchise and excise tax election are not met. 

 Print Name                                      Title                                                       

 Signature                                       Date   

             Please mail election and certified statements from distributors to: 
                                 Tennessee Department of Revenue 
                                 Taxpayer Services Division 
                                 500 Deaderick Street 
                                 Nashville, TN  37242 

                         Instructions: Certified Distribution Sales Election 
 
 Effective January 1, 2016, certain taxpayers may elect to omit certified distribution sales from the numerator of the 
 receipts factor of their franchise and excise tax apportionment ratios. Instead, for each year in effect, the taxpayer 
 will pay a tax based on the total amount of certified distribution sales excluded from the numerator of the receipts 
 factor (see Tenn. Code Ann. § 67-4-2023). 
 
 Taxpayers may make this election if they meet gross sales and gross receipts factor thresholds. The gross sales 
 threshold is met if the taxpayer’s certified distribution sales of tangible personal property made in this state during 
 the tax period exceed $1,000,000,000, as determined under Tenn. Code Ann. § 67-4-2012. The gross receipts factor 
 threshold is met if the taxpayer’s receipts factor, as determined under Tenn. Code Ann. § 67-4-2012 without regard 
 to this election, exceeds 10%. 
 
 Certified distribution sales are sales of tangible personal property made in this state by the taxpayer to any 
 distributor, whether or not the distributor is affiliated with the taxpayer, that are resold for ultimate use or 
 consumption outside the state. The distributor must certify that the property has been resold for ultimate use or 
 consumption outside this state. 
 
 Applicants must include any distributor certifications with this application. These statements should be requested 
 and retained for each year the election applies. The Department may ask for them at a later date. The distributor 
 certification should read as follows: 
 
         “[Distributor’s name] certifies that tangible personal property was purchased from [taxpayer] in this state 
         and it was resold for ultimate use or consumption outside the state.” 
 
 The election should be filed on or before the due date of the tax return for the period for which the election is to 
 take effect, and it will remain in effect until revoked by the taxpayer or until the taxpayer no longer qualifies for the 
 election. The taxpayer may revoke the election by notifying the Department in writing on or before the due date of 
 the tax return for the period for which the revocation is to take effect. 
 
 Line 1-3:  Enter taxpayer information. 
 Line 4: Enter the beginning date of the tax period the election first applies. 
 Line 5: Enter the amount of sales of tangible personal property made in Tennessee to distributors during the tax 
         period indicated on Line 4. This amount must be more than $1,000,000,000 
 Line 6: Enter the receipts factor percentage. This is determined in the same manner as the excise tax receipts 
         apportionment ratio under Tenn. Code Ann. § 67-4-2012. This amount must be higher than 10%.