Form    DP-1                         Indiana Department of Revenue
         State Form 22917 Application for Direct Payment Authorization
         (R8 / 10-20)
                          A separate application is required for each business location.

Federal Identification Number (9 digits)      Indiana Taxpayer Identification Number (TID)            Location Number (3 digits)
                                              (10 digits)

Business Entity Legal Name (sole proprietors list last name, first name)

DBA 

Mailing Address                                                        Location Address (if different)

City                                                                                 State                    Zip Code

Description of Tangible Personal Property to be Purchased Under Direct Payment Permit

___________________________________________________________________________________________________________

I hereby certify that the above statements are correct to the best of my knowledge and that I am duly authorized to sign this application. In 
consideration for issuance of this direct payment permit, I agree that I will report and pay Indiana use tax when due directly to the Indiana 
Department of Revenue on any nonexempt transaction where a direct payment certificate was issued and sales tax was not paid.

Signed   ____________________________________               Title  _______________________________          Date  ________________

Printed Name _______________________________________________________________________

Telephone Number  __________________________________                    Email  _________________________________________

                                         Information Regarding Direct Payment Permits
To apply for a direct payment permit, you must be registered with      Direct payment authorization may not be used for the purchase 
the Indiana Department of Revenue as a  retail merchant to collect     of utilities or motor vehicles required to be licensed for highway 
sales and use tax. A registered retail merchant may apply for a direct use or for property purchased in Indiana for storage in Indiana 
payment permit enabling the merchant to remit use tax directly to      and subsequent use outside Indiana as provided by the excep-
the state, rather than paying sales tax to their suppliers.            tion contained in IC 6-2.5-3-1 and 2.

Direct payment permits are issued only when the following conditions   Direct payment permits do not certify that the issuer is entitled to an 
are established:                                                       exemption and may not be issued to flat bid (lump sum) contractors. 
                                                                       Form ST-105 (general exemption certificate) should be issued if 
1.  The taxpayer regularly buys substantial quantities of  tangible    contract qualifies for exemption under IC 6-2.5-5.
   personal property that may be used for either an exempt or a 
   nonexempt purpose.                                                  Holders of direct payment permits are required to file a copy of their 
2.  There is no reasonable way the exempt or nonexempt use can         direct payment permit with their supplier in lieu of an exemption 
   be determined at the time of purchase.                              certificate. 
3.  Adequate records will be maintained by the taxpayer showing 
   the ultimate uses of all tangible personal property purchased       The tax due must be reported and paid monthly as use tax on Form 
   and the amount of use tax remitted.                                 ST-103.
4. IC 6-2.5-9-3 imposes a personal liability on any employee, 
   officer, or other person responsible for the remittance of use      For more information regarding Indiana direct payment permits, 
   tax to the department.                                              contact the department at (317) 232-3425 option 5, or email the 
                                                                       department at businesstaxcompliance@dor.in.gov.
Note: Direct payment authorization may be revoked by the depart-
ment at any time. Taxpayers with expired Registered Retail Merchant    Submit the form using this method: 
Certificates (RRMCs) will also have direct payment authorization 
revoked.                                                                •     Mail to:  Indiana Department of Revenue 
                                                                                       Business Tax Compliance
Each business location must apply for and receive a separate direct                    P.O. Box 7063
payment authorization. A consolidated sales tax filing number may                      Indianapolis, IN 46204-7063
not be used as a direct payment authorization.