Indiana Indiana Utility Exemption Certificate

Indiana Utility Exemption Certificate
Form ST-109NPG
Indiana Department of Revenue
Indiana Not-for-Profit, Governmental Unit,
and Utility Provider

Form

ST-109NP&G
State Form 56648
(R / 10-21)

Indiana Utility Exemption Certificate

Indiana registered not-for-profit entities, Indiana governmental units, federal government purchasers, and utility providers may use
this certificate. Purchaser must be registered with the Department of Revenue in order to issue this certificate. A separate certificate is
required to be completed and given to each utility provider.
Sales tax must be charged unless all information in each section is fully completed by the purchaser. Purchasers not able
to provide all required information must pay the tax and may file a claim for refund (Form GA-110L) directly with the Department of
Revenue.
Section 1 (print only)
Name of Purchaser
Principle Location Address

City

FID Number (9 digits)

State

ZIP Code

Indiana TID Number (10 digits) - Location Number (3 digits)
	

Description of How the Utility Is Used

Check this box if purchases are for resale.

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Section 2 (print only)
Provider or Seller Name

□

Utility Type

Account Number

Meter Number (if applicable)

Service Delivery Address

□

Single Meter

City

State

ZIP Code

Multiple Meters With This Provider

If you have more than one meter with this utility please attach a schedule that details the account number, meter number, and
location for each meter.
Section 3
I hereby certify under the penalties of perjury that the utility services purchased by the use of this exemption certificate are to be used
for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, under IC 6-2.5-4-5, IC 6-2.5-4-6, IC 6-2.5-5-12, IC 6-2.5-5-13,
IC 6-2.5-5-16 or IC 6-2.5-5-25; or were acquired by the federal government and are exempt under IC 6-2.5-5-24. This exemption is
subject to review by the Department of Revenue.
I confirm my understanding that misuse (either negligent or intentional), and/or fraudulent use of this certificate may subject both me
personally and the entity I represent to the imposition of tax, interest, and civil and/or criminal penalties.
Signature Entity Representative:_______________________________________ 	

Date:______________________________

Printed Name:_____________________________________________________ 	

Title:_______________________________

Telephone Number:___________________________________ 	

Email:____________________________________________

Seller must keep this certificate on file to support exempt sales.

Instructions for Completing Form ST-109NP&G
All sections of the Form ST-109NP&G must be completed or the exemption is not valid and the seller is responsible for the collection of
the Indiana sales tax. A separate ST-109NP&G must be completed and given to each utility provider.
Section 1
Name of the purchaser must be the name of the exempt entity
and must match the name on the utility account. In the case
of Indiana government units or the federal government, payment
method must represent the Indiana governmental unit or the
federal government in order to qualify for exemption. For purposes
of this form, “utility provider” includes an entity that provides, sells,
or resells electrical energy, natural or artificial gas, water, steam,
steam heating, or telecommunications services.
This section requires an Indiana Taxpayer Identification
Number. The Indiana Taxpayer Identification Number (TID) is
a ten-digit number followed by a three-digit LOC Number. This
Taxpayer Identification Number is issued to the entity by the
department upon the entity’s registration of its status with the
department as required under IC 6-2.5-8-4.

Section 2
Utility Provider Name and Type. Purchasers must complete a
separate ST-109NP&G for each utility for which an exemption is
being claimed by an eligible entity.
Enter the specific information to identify the meter for which
an exemption is being claimed. Meter information is needed for
each meter with the utility provider if the utility service is metered.
If you only have one meter, check this single meter box and enter
the meter information. If you have multiple meters with a utility
provider, check the multiple meter box and attach a schedule that
details the account number, meter number, and location for each
meter with that utility provider. In the event that the utility services
is not metered, enter delivery location information.
			

Section 3

Entity representative must sign and date the form.
Printed name and title of signer must be shown.
Providing a contact email address is optional.