51A200 (3-08)
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                 Telephone 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

                         FEIN                  E-mail Address              KY Sales and Use Account Number (if applicable)

 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, Sales and
 Use Tax Division, 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 ______________________________