51A200 (8-17)
Commonwealth of Kentucky               APPLICATION
DEPARTMENT OF REVENUE             FOR KENTUCKY ENTERPRISE INITIATIVE ACT
                                       (KEIA) TAX REFUND PROGRAM

 Name
 
                                  Enter Name as it Appears on the KEIA Application                   KEIA Number
 
 Permanent Location
 
                                  Number and Street           City or Town         State               ZIP Code
 
 Mailing Address
   (if different)
                                  Number and Street           City or Town         State               ZIP Code
 
 Other Information
 
                                  Federal Employer Identification Number              KY Sales and Use Account Number (if applicable)
 
 Contact Information
 
                                  Name                    Telephone Number            E-mail Address  
 
 Refund Requested Amount          $

  1.  A claim for refund must be filed within 60 days of completion of the project or the expiration of the life of the project, 
     whichever occurs first. A 12-month extension may be granted by the Kentucky Economic Development Finance Authority 
     (KEDFA). Only one refund request per approved project is permitted.
  2.  A refund can only be requested for Kentucky sales and use tax paid. No refund for sales tax paid to other states or localities 
     will be refunded.
  3.  If applicable, the amount of refund requested will be reduced by the amount of compensation taken when the sales or use 
     tax was paid or by the amount of any tax liability due the Commonwealth of Kentucky by the applicant.
  4.  Interest shall not be allowed or paid on any refund.
  5.  Attach a copy of the approval letter from the KEDFA.
  6.  Attach a copy of the Affidavit of Company as to Project Investment. A copy of the affidavit must be presented to KEDFA 
     prior to this refund request.
  7.  Attach copies of the information-sharing agreements with contractors, vendors or other related parties to verify construction 
     material and building fixture costs and equipment used in research and development for the approved project.
  8.  Attach the final expenditure report to the refund application. The Department of Revenue may request copies of specific 
     or all invoices relating to the project. Copies must be retained for four years. 
  9. Mail completed application and supporting documentation to the Kentucky Department of Revenue, Division of Sales 
     and Use Tax, P. O. Box 181, Frankfort, Kentucky 40602-0181.

  Any questions can be directed to the Sales and Use Tax Division at (502) 564-5170.

I, the undersigned, do declare under penalties of perjury that I have examined this application (including any accompanying statements or 
schedules and reports), and to the best of my knowledge and belief, the information and statements regarding the refundable credit for sales 
and use tax paid on purchases of building and construction materials purchased and used in the construction of the project and/or purchases 
of equipment used for research and development contained herein are true, complete and correct, and that I am duly authorized to sign this 
application.  The undersigned certifies that no tax liability of any kind is due the Commonwealth of Kentucky by this applicant.

Signed ________________________________ Title _______________________________

Date ______________________________