DOR Business Tax in Gov 2020

Form ST-200 State Form 48843 R5 / 1-18 Utility Sales Tax Exemption Application For Purchase of Metered Utility or Telecommunication Services Reverse Side Must Also Be Completed A. W.H. cubit feet or gallons breakdown for each piece of equipment. H. Certification/Signature I hereby certify under penalty of perjury that the foregoing is true and correct to the best of my knowledge that all equipment has been listed and that the power ratings of all listed equipment have been visually verified. Authorized Signature Printed Name Email Date Signature of Utility Study Printed Name Email Date Preparer Instructions for Completing Form ST-200 The information requested on the ST-200 enables the Indiana Department of Revenue to the exempt status of metered utility or telecommunication services. Mailing Address B. Meter Location Address Legal Name DBA doing business as Name Street/P. O. Box City State ZIP Telephone Number C. Billing Name a copy of the utility bill with billing name must be attached 12 months of bills are attached 1 bill showing annual usage is attached D. Fill In All Applicable Blanks Nonprofit organizations and governmental entities should NOT complete the lines with the. On the reverse side only complete the Summary Section E and sign and date the form* 1 Indiana Taxpayer Identification Number TID 2 Location three digit location number 3 Social Security Number farmers only 4 Federal ID Number 5 Name of Utility Company 6 Meter Number only 1 meter per application 7 Account Number from utility bills Type of Energy/Utility Service 8 telephone gas electric steam or water 9 Average Monthly Bill Annual K. W*H. Cubic Feet or Gallons 10 used in previous calendar year 11 Total Hours of Operation Per Day 12 Number of Operational Days Per Week For Department Use Only Employee Name Exempt Disposition User ID NAICS Code Issue ST-109 Date POA Yes No Audit Case E* Summary Please provide a brief overview of your operation* Explain how the utility is used* Note Registered nonprofit organizations and governmental entities go to H. F* Supporting Schedule See Instructions Utility Usage Study Production List all production and nonproduction equipment with the annual energy consumption with K. W*H. cubit feet or gallons breakdown for each piece of equipment. G* Utility Usage Study Research Development R D List all R D and Non R D equipment with annual energy consumption with K. Complete a separate application for each meter and/or telephone account. Fill in all blanks. Any applications that are missing information or are incomplete will be rejected which will delay the processing of your application* Section A Mailing Address You must apply using the legal name of the business entity. Please enclose a copy of the utility bill with the legal name to speed up the review of the application* Section B Meter Location Address Provide the location address of the meter or communication service. Section C Billing Name A complete copy of the utility billings with billing name location meter number and account number must be attached* If this information isn t available on the bill other documentation will need to be provided* For example a screen shot of your online utility account or something from the utility company on their letterhead with the information needed* Annual utility usages must be documented* Attach either 12 months of billings or one month that has the annual usage documented typically in a usage graph.