Declaration of Domicile

Please review the FULL FORM before filling it out below. You can also download/print the Declaration of Domicile for Purchase of Residential Utilities form.

LANDLORDS OR OTHER ACCOUNTHOLDERS OF MULTI-UNIT DWELLINGS SERVED BY A SINGLE METER (MASTER METER) USE THE MULTI-UNIT DECLARATION OF DOMICILE

In accordance with provisions of KRS 139.470(7) this declaration may only be executed for the purchase of sewer services, water, and fuel by Kentucky residents for use in heating, water heating, cooking, lighting, and other residential uses. "Fuel" shall include but not be limited to natural gas, electricity, fuel oil, bottled gas, coal, coke, and wood.

Name of Account Holder: Service Address: Name of Individual Signing the Declaration: Relationship of the undersigned to the resident:

I declare that the address listed is my place of domicile* or the place of domicile* of:

Name of Resident:

and the purchase of residential utilities for use at this address meets the qualifications for exemption from Kentucky sales and use tax under KRS 139.470(7).

Accordingly, I request the account associated with the above listed service address be classified as exempt from sales and use tax. I understand the exemption will begin on the date of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative.

Under penalties of perjury, I swear or affirm that the information on this declaration is true and correct as to every material.

Signature of Resident: Date:

* KRS 139.47(7) describes a place of domicile as "the place where an individual has his or her legal, true, fixed and permanent home and principal establishment, and to which, whenever the individual is absent, the individual has the intention of returning."