Application for Owner with Domicile Form

51A380 (1-23)
DEPARTMENT OF REVENUE
DECLARATION OF DOMICILE FOR PURCHASE OF RESIDENTIAL UTILITIES
(LANDLORDS OR OTHER ACCOUNTHOLDERS OF MULTI-UNIT DWELLINGS SERVED BY A SINGLE METER (MASTER METER) USE THE MULTI-UNIT DECLARATION OF DOMICILE)
Inaccordance 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,
Name of Accountholder*
Service Address*
Name of Individual Signing the Declaration (cannot be landlord)*
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 matter. Check all that apply: Water Service Sewer Service
Signature of resident or representative*

Clear
Date*

MonthDayYear
Date
. KRS 139.470(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."

Submit the Declaration of Domicile to each applicable utility provider or rural electric cooperative, not to the Department of Revenue. 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. Department of Revenue Contact Information:

Email: DOR.Webresponsesalestax@ky.gov
La Grange Utilities Commission

412 E. Jefferson St. La Grange KY 40031

APPLICATION FOR HOMEOWNER - A non-refundable origination fee is required.
(Address)*
Name*

(First Name)(Middle Initial)(Last Name)
(Date of Birth)*

MonthDayYear
Date
(Social Security Number)
(Phone Number)*
(Email)*
example@example.com
(Emergency Contact)*
(Phone Number)*
(Employer)
(Phone Number)
(Billing Address, if different from above)
Co- Applicant Only those listed on this form may have access to account information.
Name

(First Name)(Middle Initial)(Last Name)
(Date of Birth)

MonthDayYear
Date
(Social Security Number)
(Phone Number)
(Email)
example@example.com
Bysigning below, I ask that an account be opened by me. I will be bound by the Agreement received.I understand that when the service is turned off for non-payment of bill, the reconnection fee is $50.00. Ihave read the "Rules and Regulations", and "the Disconnection Policy" for customer service and agree to abide by them. Primary ResidenceOther Rental Property
Type a question*

Primary ResidenceRental PropertyOther
If home is going to be a rental property, does it need to be a read and leave on account. (When a renter leaves, the property will automatically revert to your name if you select yes.)

YesNo
(Signature of Applicant)*

Clear
(Date)*

MonthDayYear
Date
(Co Applicant Signature)

Clear
(Date)

MonthDayYear
Date
(Service Start Date)*

MonthDayYear
Date
(Driver's License (ID) Number)
(Signature of employee receiving origination fee)

Clear
Pay online @ LaGrangeutilites.com
Should be Empty:

51A380 (1-23)

DEPARTMENT OF REVENUE

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