REQUEST FOR PROJECT EXEMPTION CERTIFICATE 
                          PURSUANT TO K.S.A. 79-3606 (cc) OR K.S.A. 79-3606(hhhh) 
Kansas Department  of Revenue                                                                                         Telephone: 785-296-3081 
Office of Policy and Research                                                                                                  FAX: 785-296-7928 
915 SW  Harrison St. 
Topeka, KS  66612-1588                                                                                          Date:                                  
It is  requested that a Certificate of Exemption from sales tax be issued to the taxpayer for the following described project. 

(A)   Name of taxpayer:                                                                                EIN:                                            
           Business type:    Corporation                   L.L.C.        Limited Liability Partnership/Partnership                 Individual  
            Other:                                                                                                                                    
(B)   1.   Name of business which will  operate the business facility (if  different from the name listed on Line (A)):  
                                                                                                       EIN:                                            

           Business type:    Corporation                    L.L.C.       Limited Liability Partnership/Partnership                 Individual 
            Other:                                                                                                                                    
      2.   Location of business  facility investment:                                                                                                  
                                                                                      Street Number and Address  
           County:                                  City   :                                            State:         ZIP:                            
      3.   Mailing address of  taxpayer (business) who will own and/or  operate the business facility:  
                                                                                                                                                       
                                                            Box Number  and/or Street Number and Name  
           City:                                                                                        State:          ZIP:                           
      4.    Email Address:                                                                                                                             

(C)	  Type of project:       Original construction of a new facility                  Remodel or reconstruction of  an existing facility  
                             Addition to an existing facility                         Additional machinery and equipment, not to include  
                                                                                           the purchase of a motor vehicle or trailer.  
(D)	  ATTACH an explanation or list  of improvements to be constructed, repairs or remodeling to be done, and machinery and equipment  
      to be purchased.  
(E) 	 Describe specifically the type of business activity to be conducted by the taxpayer [name on Line (A)] at the  business facility:  
                                                                                                                                                       
(F) 	 Indicate the type of business conducted by  the named taxpayer. See instructions. 
       1.        CERTIFIED BUSINESS-K.S.A. 79-3606(cc)  
                  The  business   has   been  certified   by   the   Department   of   Commerce  as   meeting  the  eligibility   criteria  for   the  High 
                  Performance Incentive Program (HPIP). Attach a copy of the letter of  certification.  
          2.     AGRICULTURAL BUSINESS-K.S.A. 79-3606(hhhh)  
                  The business  must have a project with actual costs of $50,000 or more and must be identified under the North American  
                  industry classification system (NAICS) subsectors 112112,   112120,  112210,  1123, or  1124, (See  instrs).  
(G)	  Is this  project  a result  of working with officials of the state, county, or  city government?         Yes    No 
      If yes, provide the name of the agency  and contact:                                                                                             
      What will be the average annual wage for  new (non-managerial) employees?                                                                        
(H)	  List the name(s) and address(es)   of   the general contractor(s):                                                                               
(I) 	 Estimated project costs: Total:                                             Construction costs:                                                  
      Machinery and equipment  costs:                                       
(J) 	 Contract date:                                                         (K) Contract No.:                                                         
(L) 	 Estimated completion date (not to exceed two years):                                                                                             

                          Taxpayer (please type or print)	                                 Name of Authorized Representative (please type or  print)  

Signature of Authorized Representative                         Title                                             Phone Number  

PR-70b Rev. 7-14  

                                                         INSTRUCTIONS 

Certified Business   - K.S.A. 79-3606(cc): An exemption from sales tax is allowed on all sales of tangible personal property or               
services purchased for  the construction,   reconstruction,   enlarging or remodeling of      a business that has been certified through the 
High Performance Incentive Program (HPIP). The sale and installation of machinery and equipment purchased for installation at 
the business shall also be exempt from sales tax.  

Agricultural Business   - K.S.A. 79-3606(hhhh): An exemption from          sales   tax   is allowed on and after July   1, 2014 for all sales   of 
tangible  personal property or  services purchased for the construction, reconstruction, enlarging or remodeling of a business                
identified under the North American industry classification system (NAICS) subsectors: 112112-Cattle Feedlots; 112120-Dairy                   
Cattle and Milk Production; 112210 Hog and Pig Farming; 1123-Poultry and Egg Production; or 1124-Sheep and Goat Farming.  
This qualifying NAICS must be on file  with the Kansas Department of   Labor for your specific facility address that has been 
provided on this application. The sale and  installation   of machinery    and equipment    purchased  for  installation at the business shall 
also be exempt from sales tax. Only those projects that have total actual costs of          $50,000 or more will qualify. 

Line (A) 	    Enter the name of the entity that will operate the business facility and claim the sales tax exemption, the                     
              employee identification number (EIN) and check the appropriate box identifying the business type. 
Line (B)(1) 	 Enter the name and EIN       of the business,       if it is different than line (A), above, and check  the   appropriate box 
              identifying the business type. If the taxpayer on line (A) operates under a Doing Business As           (DBA) name, enter       
              the DBA. 
Line (B)(2)	  Enter the location, including the county of the business facility where the investment is going to be made. 
Line (B)(3) 	 Enter the complete mailing address   of the taxpayer who        will own and/or operate  the above referenced business          
              facility. 
Line (B)(4) 	 Enter the email address of the authorized representative for the taxpayer. 
Line (C)  	   Check the applicable box(es) that describe the project and attach required documentation. 
Line (D)  	   Attach an explanation  or list of       improvements to  be  constructed, repairs or  remodeling        to be done,  and        
              machinery and equipment to be purchased. 
Line (E) 	    Describe specifically the type of business activity to be conducted by the taxpayer at the business facility. 
Line (F) 	    Indicate the type of business activity to be conducted at the business facility by the named taxpayer. 
Line (F)(1) 	 Certified Business - K.S.A. 79-3606(cc): Certified business means a firm which is qualified             by the Secretary     of 
              Commerce as meeting the eligibility       criteria for the High Performance Incentive Program (HPIP) pursuant to K.S.A. 
              2003 Supp. 74-50,131. The firm must be entitled to         the corporate tax  credit established  in K.S.A.  74-50,132 or must 
              have received written approval for participation and has participated, during the tax year in which the exemption is 
              claimed, in training assistance by the Department of Commerce under the             Kansas   industrial training (KIT),   Kansas 
              industrial retraining (KIR)   or state of Kansas investments    in lifelong learning program (SKILL). ATTACH a copy of the 
              PD (project description) submitted to the Department   of Commerce pre-identifying this            investment as well as the 
              initial correspondence from the    Department   of Commerce assigning the project        number. 
Line (F)(2) 	 Agricultural Business  –K .S.A. 79-3606(hhhh):  An agricultural business               must be identified  under the  North 
              American industry classification system    (NAICS)      subsectors:  112112-Cattle Feedlots;    112120-Dairy Cattle and Milk 
              Production; 112210 Hog and Pig Farming; 1123-Poultry and Egg Production; or 1124-Sheep and Goat Farming.  This  
              qualifying NAICS must be on file with the Kansas Department   of Labor for your          specific facility address that   has been 
              provided on this application. Only those projects that have total     actual  costs of $50,000 or  more will qualify. 
Line (G) 	    Check the applicable box and list the name of           the organization and/or person   you were contacted by and the          
              average wage of the new (non-managerial) employees. 
Line (H)  	   List the name and address of the general         contractor if available. If a general contractor does     not exist for this   
              project, please attach a list      of all the contractors/subcontractors (if available) involved in performing labor            
              services or supplying   materials     for  the  project.  Include in this list, the estimated project costs, contract date,     
              contract number, and the estimated completion date for each contract. 
Line (I) 	    Enter the estimated cost of the project. 
Line (J) 	    Enter the date of the contract. 
Line (K) 	    Enter the applicable contract number if available. 
Line (L) 	    Enter the estimated completion date for this project. The Department requests that this period not extend beyond 
              two years from the application date. 
Signature 	   The name of the taxpayer as well as the authorized representative requesting the exemption should be typed or                   
              printed in the area provided. The authorized representative must also sign the request                and provide a phone       
              number where they can be reached during business hours.