Member Services

Declaration of Domicile

NOTE: Fields marked * are required.

Name of Resident:
Please enter your email address.
*Email Address:
*Service Address:
*Account Number:
*City:
*State:
*Zip Code:
If you are signing and submitting this form for someone else, please enter the fields below:
Your Name:
Your Relationship to the Resident:

If you qualify, complete the Declaration of Domicile (below) to be exempt from sales and use tax on your purchase of electricity. Fill in your name in the first box and your full address in the second box and provide your signature and enter the date.
Click the Submit button at the bottom of the form.

Declaration of Domicile for Purchase of Residential Utilities

In accordance with the 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. KRS 139.470(7) describes a place of domicile as "the place where an individul 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."
is the accountholder for . I , am the resident or to the Resident. I declare that the address listed is my place of domicile or the place of domicile of 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 matter.
Each resident may have only one place of domicile but may be listed as a responsible party for other service addresses. The change in taxability for accounts will be effective on the first day of the first full billing cycle after the date of receipt of this declaration by the utility provider or rural electric cooperative.

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Signature of Resident

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Date: (MM/DD/YYYY)