Residential Sales Tax Exemption Form

To make sure the sales tax is not mistakenly applied to the Utilities bill of your primary residence starting January 1, 2023, residential members need to take action. Customers need to declare which meter or meters is/are associated with their primary residence. Failure to provide a completed declaration form may result in the loss of a sales tax exemption for members who have multiple meters in their name.

Please Fill out ONE form per residential account.

DECLARATION OF DOMICILE FOR RESIDENTIAL UTILITIES ONLINE FORM
This online form is for residential utilities provided by City of Vine Grove only. Complete a separate form for each residential service address. 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.

Account Holder Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Is this service address the primary domicile( residence) of account holder?

If this service address is NOT the primary domicile for the account holder, who resides at this service address? Please include first and last name.

Authorized Signature(Required)

First Last

I declare that the address listed is my place of domicile* or the place of domicile* of the resident I have listed here 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. * 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.”