51A109 (2-11)                                                     APPLICATION FOR
Commonwealth of Kentucky                              ENERGY DIRECT PAY AUTHORIZATION
DEPARTMENT OF REVENUE                         (Sales and Use Tax and Utility Gross Receipts License Tax) 
  Thisformshouldbesubmittedonlybypersonsengagedinthebusinessofmanufacturing,industrialprocessing,mining,orrefiningwhodocumentthatthecosttothemof
  energyorenergy-producingfuelexceeds3percentofthecostofproduction.ARetailSalesandUseTaxPermitmustbeobtainedbyallpersonswhoobtainanEnergyDirect
  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,”givefiscalyearendingdate:                                              (Day)
                                     IndicatethelastperiodforwhichaKentuckyincometaxreturnwasfiled.
                                     Wasabalancesheetforthebusinessincludedinthelastincometaxreturnfiled?              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?
                                        Athowmanyoftheselocationsdo(es)manufacturing,industrialprocessing,mining,orrefiningoccur?
                                    (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%) ........................................................   ______________________
  EstimatedMonthlyCostofEnergyorEnergy-ProducingFuelSubjecttoSales               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 ............................................................................................................................   ______________________
  LessEnergynotSubjecttoUGRLT             (See Instructions)  ..................................................................................................................   ______________________ 
  BalanceofEnergySubjecttoUGRLT           (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% ) ...........................................................................................................    ______________________
   EstimatedMonthlyCostofEnergySubjecttoUGRLT               (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 
forissuanceofthisEnergyDirectPayAuthorization,IwilldirectlyreportandpaytotheDepartmentofRevenuethesalesorusetaxand/ortheUGRLT,onanyenergyorenergy-
producingfuelpurchasedbymewithoutpaymentofsalesorusetaxpursuanttoKRS139.480andRegulation103KAR30:140,and,ifapplicable,theUGRLTpursuanttoKRS
160.613.
                                                                                                                      Mail to:
                                                                                                                      Kentucky Department of Revenue
Signature _____________________________________  Title ______________________________
                                                                                                                      Division of Sales and Use Tax
                                                                                                                      PO Box 181
Print Name ___________________________________        Date ______________________________                             Frankfort, KY 40602-0181

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
lastcompletedcalendarorfiscalyear)ofallcostsincludedincomputingthecostofproductionexceptforthecostofenergyor
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.
Thefollowingaccountsorsimilarclassificationsshouldbeincludedinthecostofproductioncomputation:
                       DirectMaterials
                       DirectLabor
                       OverheadExpenses:
                             DepreciationforPlantEquipment
                             Insurance for Plant Equipment
                             Taxes for Plant Equipment
                             RentorDepreciationforPlantBuilding
                             Heat, Lights, and Water
                             Compensation Insurance
                             IndirectMaterials
                             Indirect Labor
                             MiscellaneousFactoryExpenses
                             Administrative Expenses Allocated to Cost of Production
                             OfficeExpensesAllocatedtoCostofProduction

                       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 
    totheDepartmentofRevenue.
(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 willberequiredtoreporttheEstimatedMonthlyCostofEnergyorEnergy-ProducingFuelSubjecttoTaxeachmonth
    on Line 23b of the Sales and Use Tax Return (Form 51A102) and, if applicable, on Line 5b of the monthly UGRLT return. 
    Anannualreturnfor eachauthorized taxexemption must befiled within four months after theend ofyour calendar or
    fiscalyearreconcilingtheestimatedcostofenergyorenergy-producingfuelsubjecttotaxwiththeactualcostsubjectto
    taxfortheperiod.Theseforms(Form51A109andForm73A902)willbeavailableontheDepartmentofRevenueweb
    site: www.revenue.ky.gov. Any additional tax due must be paid with the annual return(s). If amounts were overpaid on the 
    monthlyreturns,arefundwillbeissuedor,forUGRLTEDPonly,creditmaybetakenontheestimateforthesucceeding
    year.