51A209 Form – Fill Out and Use This PDF

Name of

(

)

Business

Enter Exact Name as it Appears on Your Permit (please print or type)

Telephone Number (include area code)

Location of

Business

Number and Street

City or Town

County

State

ZIP Code

Mailing

Address

P.O. Box or Number and Street

City or Town

County

State

ZIP Code

(1)

Sales and use tax account number under which tax was paid to the Kentucky State Treasurer.

___________________________________

(2)

Period(s) in which tax was reported and paid. ________________________________________________

Attach detailed schedule if more than one period involved.

(3)

Amount of tax refund requested. ___________________________________________________________

(4)

Was compensation claimed when tax was remitted to the state?

Yes

No

(5)

Was sales or use tax added to the sales price (bracket system) and collected from the purchaser(s) as a

separate charge?

Yes

No. If yes, will the tax be refunded to the purchaser(s)?

Yes

No

(6)

Explain in detail the reason(s) for refund. Attach schedule and copies of pertinent invoices, resale certificates

and/or exemption certificates if applicable. Attach separate sheet if necessary.

_______________________________________________________________________________________

_______________________________________________________________________________________

(7)

Banking Information (if electronic fund transfer requested)

Name of Bank __________________________________________________________________________

Depositor Account Number (DAN) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Routing Transit Number (RTN) __ __ __ __ __ __ __ __ __ Account Type:

Checking

Savings

Other

(1)

This application must be completed in order for consideration to be given to the refund request. Substitutions

will not be accepted, nor will they preserve your rights to a refund.

(2)

Only the person making payment of the tax directly to the Kentucky State Treasurer may file the application

for refund. Compensation, if claimed, will be deducted from any refund.

Instructions

(3)

Claims for refunds or credits must be filed within four years from the date the tax was paid to the State

Treasurer. After the statute of limitations has expired, no claims for refunds or credits will be considered.

(4)

No taxpayer will be issued a refund or credit for sales or use tax where the tax has been collected from a

purchaser as provided by KRS 139.210 and 139.340, unless the amount of tax collected from the purchaser

is refunded to him by the taxpayer who paid the tax to the State Treasurer.

(5)

Mail completed application to the Department of Revenue, Division of Sales and Use Tax, P.O. Box 181,

Frankfort, Kentucky 40602-0181.

Signed

Title

Name

Date