Mt. Washington Water Service Form

I (we) hereby authorize Mt. Washington Water Co., hereinafter called Company, to initate debit enteries to my (our) checking account indicated below and the depository named below, hereinafter called Depository, to debit the same to such account.

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51a380 (1-23)

Commonwealth of Kentucky   

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-METER DECLARATION OF DOMICILE)

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.

is the account holder for

am the resident or

I declare that the address listed is my place of domicile* or the place of domicile* of

and the purchase of the residential utilities for use that 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 electec 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.*

Instructions

• Submit the Declaration of Docmicile 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 the receipt of this declaration by the utility provider or rural electric cooperative.

Department of Revenue Contact Information:

Phone: 502-564-5170

Email: DOR.Webresponsesalestax@ky.gov

Mt. Washington Water & Sewer Co.

311 Snapp Street

P.O. Box 285

Mt. Washington, KY 40047

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A security deposit of $200.00 is required for all accounts. A representative will reach out to you to collect the deposit and activate your account.

By signing below, you acknowledge that the city of Mt. Washington Water and Sewer Company reserves the right to provide notice to the property owner / landlord in the event this account becomes delinquent.

By signing below, you agree to all terms and conditions and hereby give permission to The Mt. Washington Water Company to activate your account using the information you have provided above. Please be aware all necessary fees must be paid in full to activate your water account.

NOTE: Please upload/attach a copy of your Driver's License.

NOTE: Please upload/attach a copy of your Driver's License and a copy of your signed Rental/Lease agreement.