51A109 (1-21)                                                    APPLICATION FOR
Commonwealth of Kentucky                             ENERGY DIRECT PAY AUTHORIZATION
DEPARTMENT OF REVENUE                           (Sales and Use Tax and Utility Gross Receipts License Tax) 
  This form should be submitted only by persons engaged in the business of manufacturing, industrial processing, mining, or refining who document that the cost to them of 
  energy or energy-producing fuel exceeds 3 percent of the cost of production. A Retail Sales and Use Tax Permit must be obtained by all persons who obtain an Energy Direct 
  Pay Authorization. If you require a Retail Sales and Use Tax Permit and have not submitted a Kentucky Registration Application (Revenue Form 10A100), submit that form 
  with this application. If you choose to apply for the UGRLT exemption, you must register for a UGRLT number and you will be required to file monthly UGRLT 
  returns via KY E-Tax. **
  Name of Business
                                                                                                                           (    )
                                   Enter Exact Name of Business                                                                                                             Telephone Number
  Location of Facility
  (authorization is site specific)
                                   Number and Street                               City                          County                                                     State   ZIP Code
  Mailing Address
  (if different from above)
                                   P.O. Box or Number and Street                   City                          County                                                     State   ZIP Code
  Nature of Business               IMPORTANT: An accurate description of your business is necessary.
  at this Location

  Questionnaire                    (1) Are books kept on a calendar year basis?     Yes         No
                                       If “No,” give fiscal year ending date: (Month)                                     (Day)
                                   (2) Indicate the last period for which a Kentucky income tax return was filed.
                                   (3) Was a balance sheet for the business included in the last income tax return filed?   Yes                                              No
                                       If “No,” submit a copy of the most recent balance sheet with this application.
                                   (4) How many business locations do you operate in Kentucky?
                                       At how many of these locations do(es) manufacturing, industrial processing, mining, or refining occur?
                                   (5) In what school district is the plant facility located?**
  Identification                   Utility Gross Receipts License Tax (UGRLT) Number (if already issued)**
  Numbers                          Sales and Use Tax Permit Account Number
                                   Kentucky Corporation Income Tax Number
  Supplier and Amount                                                                                      Type of Energy                                                    Cost of Energy or
  of Energy or Energy-                                                                                    or Energy-Producing                                               Energy-Producing Fuel
                                        Name of Supplier                 Address of Supplier               Fuel Purchased                                                    Purchased in Previous Year
  Producing Fuel
  (Submit copies of vendor
  invoices)

                                                                                                                     Total Amount
  Sales and Use Tax EDP Computation
  (1)  Cost of Production in Previous Year Excluding Cost of Energy or Energy-Producing Fuel............................................................    ______________________
       (Attach separate schedule detailing Cost of Production) (See Instructions)
  (2)  Enter 3% of Cost of Production Excluding Energy or Energy-Producing Fuel (Line 1 x 3%) ........................................................    ______________________
  (3)  Estimated Monthly Cost of Energy or Energy-Producing Fuel Subject to Sales Tax (Line 2 ÷12) ................................................    ______________________
  UGRLT EDP Computation**
   **If you choose to apply for the UGRLT exemption, you must register for a UGRLT number and you will be required to file
  monthly UGRLT returns electronically via KY E-Tax.**
  Do you wish to apply for the UGRLT exemption at this time? Circle Yes or No .............................................................................   Yes                 No
  If “Yes”, then questions (4) through (9) must be completed for this document to be considered an application for UGRLT EDP.**
  (4)  Total Cost of Energy Purchased in Previous Year ............................................................................................................................    ______________________
  (5)  Less Energy not Subject to UGRLT (See Instructions)  ..................................................................................................................    ______________________ 
  (6)  Balance of Energy Subject to UGRLT (Line 4 - Line 5) ..................................................................................................................    ______________________
  (7)  Cost of Production for UGRLT Computation (Line 1 + Line 5) ......................................................................................................    ______________________
  (8)  Enter 3% of Cost of Production for UGRLT  (Line 7 x 3% ) ...........................................................................................................    ______________________
  (9)  Estimated Monthly Cost of Energy Subject to UGRLT (Line 8 ÷12)  .............................................................................................         ______________________
   
I hereby certify that the above statements are correct to the best of my knowledge and belief and that I am duly authorized to sign this application. I agree that, in consideration 
for issuance of this Energy Direct Pay Authorization, I will directly report and pay to the Department of Revenue the sales or use tax and/or the UGRLT, on any energy or energy-
producing fuel purchased by me without payment of sales or use tax pursuant to KRS 139.480 and Regulation 103 KAR 30:140, and, if applicable, the UGRLT pursuant to KRS 
160.613.
                                                                                                                     Mail to:
Signature _____________________________________  Title ______________________________                                Kentucky Department of Revenue
                                                                                                                     Division of Sales and Use Tax
Print Name  ___________________________________   Date ______________________________
                                                                                                                     PO Box 1303
E-mail Address ____________________________________________________________________                                  Frankfort, KY 40602-1303

If you choose to apply for the UGRLT energy exemption, you must complete all sections denoted with a double asterisk 
(**) and you will be required to file monthly UGRLT returns electronically via KY E-Tax.

                                              INSTRUCTIONS
Complete all information requested on the reverse side of this form. Include copies of invoices for all energy purchases made 
in the last completed fiscal or calendar year. Attach a schedule showing the account classification and amount (based on the 
last completed calendar or fiscal year) of all costs included in computing the cost of production except for the cost of energy or 
energy-producing fuel. The cost of production must be computed on the basis of plant facilities. The term “plant facilities” 
means all permanent structures affixed to real property at one location. Therefore, if you operate more than one facility, 
an application must be completed on each location for which you are seeking the Energy Direct Pay Authorization.
The following accounts or similar classifications should be included in the cost of production computation:
                       Direct Materials
                       Direct Labor
                       Overhead Expenses:
                            Depreciation for Plant Equipment
                            Insurance for Plant Equipment
                            Taxes for Plant Equipment
                            Rent or Depreciation for Plant Building
                            Heat, Lights, and Water
                            Compensation Insurance
                            Indirect Materials
                            Indirect Labor
                            Miscellaneous Factory Expenses
                            Administrative Expenses Allocated to Cost of Production
                            Office Expenses Allocated to Cost of Production

                       SPECIAL INSTRUCTIONS FOR COAL MINES AND QUARRIES
The following accounts must also be included in the cost of production: Rents, Royalties, Cost Depletion, Reclamation and 
Severance Tax.

                                            **UGRLT EDP ONLY**
    SPECIAL INSTRUCTIONS FOR FACILITIES UTILIZING OTHER FUELS AS AN ENERGY SOURCE

    When calculating the amount of energy relative to the UGRLT energy exemption, please note that energy or energy-
    producing fuel such as diesel fuel, coal, coke, fuel oil, kerosene, propane, steam, nitrogen and bottled gases are not 
    subject to the UGRLT, therefore they are excluded in the calculation of energy costs. However, such energy costs 
    are included in the cost of production, as evidenced by the addition of Line 5 to Line 1 to obtain the UGRLT cost of 
    production on Line 7. If your allowable cost of energy exceeds the 3 percent cost of production, you qualify for the 
    energy exemption for the UGRLT. 

IF YOUR APPLICATION IS APPROVED:

(1) You will be permitted to purchase all energy or energy-producing fuel for the qualifying facility without payment of the sales 
    or use tax, and if applicable, the UGRLT. You will be required to estimate the cost of such energy or energy-producing fuel 
    which does not exceed 3 percent of the cost of production, and remit the applicable tax on the estimated amount monthly 
    to the Department of Revenue.
(2) A letter of authorization for each applicable exemption will be mailed to you. You must forward a copy of the letter(s) to 
    each of your suppliers of energy or energy-producing fuel, and the letter(s) must be maintained by the suppliers to verify 
    non-taxability of the energy purchases. 
(3) You will be required to report the Estimated Monthly Cost of Energy or Energy-Producing Fuel Subject to Tax each month 
    on Line 23b of the Sales and Use Tax Return (Form 51A102) and, if applicable, on Line 5b of the monthly UGRLT return. 
    An annual return for each authorized tax exemption must be filed within four months after the end of your calendar or 
    fiscal year reconciling the estimated cost of energy or energy-producing fuel subject to tax with the actual cost subject to 
    tax for the period. These forms (Form 51A109 and Form 73A902) will be available on the Department of Revenue web 
    site: www.revenue.ky.gov. Any additional tax due must be paid with the annual return(s). If amounts were overpaid on the 
    monthly returns, a refund will be issued or, for UGRLT EDP only, credit may be taken on the estimate for the succeeding 
    year.