Purchase Exemption Certificate 51A126

PURCHASE EXEMPTION CERTIFICATE

Important - Certificate not valid unless completed.
51A126 (12-09)
What type of service(s) is used by exempt institution? (select all that apply)*

WaterSewer
Name of Exempt Institution*
(S) Name of Exempt Institution*
Exempt Institution Address*

Street Address

Street Address Line 2

CityState

Zip Code
(S) Exempt Institution Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number for Applicant*
Please enter a valid phone number.
(S) Contact Phone Number for Applicant
Please enter a valid phone number.
Contact Email for Applicant*
example@example.com
(S) Contact Email for Applicant
example@example.com
Select a Classfication for the Exempt Institution*
(S) Select a Classfication for the Exempt Institution
Exemption Number*
Sales Tax Exempt Number issued by Ky Department of Revenue
(S) Exemption Number*
Sales Tax Exempt Number issued by Ky Department of Revenue
PURCHASE EXEMPTION*

BlanketSingle Purchase
(S) PURCHASE EXEMPTION*

BlanketSingle Purchase
Water Provider
Water Provider Address
Service Type: Water
Select your Sewer Service Provider
(S) Select your Sewer Service Provider
Service Type: Sewer
(S) Service Type: Sewer
Account # with Oldham Co. Water District*
12 digit account # XXXX-XXXXX-XXX
Do you have more than one account with Oldham County Water District?*

YesNo
Account # with Oldham Co. Water District (2)*
12 digit account # XXXX-XXXXX-XXX
Do you have another account with Oldham County Water District?*

YesNo
Account # with Oldham Co. Water District (3)*
12 digit account # XXXX-XXXXX-XXX
Do you have another account with Oldham County Water District?*

YesNo
Account # with Oldham Co. Water District (4)*
12 digit account # XXXX-XXXXX-XXX
In the event that the property purchased is not used for an exempt purpose, it is understood that I am required to pay the tax measured by the purchase price of the property. Any official or employee who uses this certificate to make tax-free purchases for his own personal use or that of any other person will be subject to the penalties provided in KRS 139.990 and other applicable laws. Under penalties of perjury, I swear or affirm that the information on this certificate is true and correct as to every material matter.
Print Name of Authorized Signer*
(S) Print Name of Authorized Signer
Authorized Signature for Water Service Tax Exemption*

Clear
Authorized Signature for Sewer Service Tax Exemption*

Clear
Title*
(S) Title*
Date*

MonthDayYear
Date
(S) Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

PURCHASE EXEMPTION CERTIFICATE

51A126 (12-09)