Indiana Utility Sales Tax Exemption Application

Utility Sales Tax Exemption Application
Form ST-200
Form ST-200
State Form 48843
(R13 / 1-23)

Utility Sales Tax Exemption Application

For Purchase of Metered Utility or Telecommunication Services
Applicant must also complete the reverse side.

A. Legal Address
Legal Name

Telephone Number

Street/P.O. Box

City, State, ZIP

B. Meter Location Address
DBA (doing business as) Name

Telephone Number

Street

City, State, ZIP

C. Billing Name (A copy of the utility bill with billing name must be attached.)
Billing Name

Franchise Name, if applicable

□ 12 months of bills are attached □ This is a new meter □ One for one change
D. Fill In All Applicable Blanks
On the reverse side, all Applicants must complete section E; complete other sections as applicable.
1. Indiana Taxpayer Identification Number (TID)

2. Location (three digit location number)

3. Social Security Number (farmers only)

4. Federal ID Number

5. Name of Primary Utility Company
6. Meter Number (only 1 meter per application)

7. Account Number (from utility bills)

8. Name of Secondary Utility Company (if applicable)
9. Account Number

10. Type of Energy/Utility Service (telephone, gas, electric, steam, or water)

11. Average Monthly Bill

12. Annual K.W.H. Cubic Feet or Gallons (used in previous calendar year)

13. Total Hours of Operation per Day

14. Number of Operational Days per Week

15. Number of Operational Weeks per Year

16. What exemption percentage are you requesting?

For Department Use Only
Employee Name

Exempt %

Disposition

User ID

NAICS Code

Issue ST-109

Date

POA

□ Yes □ No

Audit Case Number

□ Yes □ No

E. Summary
Please provide a brief overview of your operation. Explain how the utility is used.

F. Supporting Schedule (See Instructions) Utility Usage Study: Production
List all production and nonproduction equipment with the annual energy consumption with K.W.H., cubit feet, or gallons breakdown
for each piece of equipment.

G. Utility Usage Study: Research & Development (R&D)
List all R&D and Non R&D equipment with annual energy consumption with K.W.H., cubit feet, or gallons breakdown for each piece of
equipment.

H. Certification/Signature

I hereby certify under penalty of perjury that the foregoing is true and correct to the best of my knowledge, that all
equipment has been listed, and that the power ratings of all listed equipment have been visually verified.
_________________________ 	 ________________________	 __________________________ 	 ______________
Authorized Signature		 Printed Name		 Email		 Date	
_________________________ 	 ________________________	 __________________________ 	 ______________
Signature of Utility Study		 Printed Name		 Email		 Date
Preparer

Instructions for Completing Form ST-200
The information requested on the ST-200 enables the
Indiana Department of Revenue (DOR) to verify the exempt
status of metered utility or telecommunication services.
With the submission of Form ST-200, your meter location
address may be subject to an on-site inspection by DOR.
Complete a separate application for each meter and/or
telephone account. Fill in all blanks. Any applications that
are missing information or incomplete will be rejected thus
delaying the processing of your application.
Note. The Utility Sales Tax Exemption Application can also
be submitted electronically via DOR’s secure e-service
portal INTIME at intime.dor.in.gov.
If there are any changes in the manner in which the utility
is used, changes in ownership of the business, or the
addition or deletion of equipment connected to the meter
(for water, gas, electricity, or steam), a new application will
be required.
Section A: Mailing Address. You must apply using the
legal name of the business entity. Enclose a copy of the
utility bill with the legal name to expedite the application
review.
Section B: Meter Location Address. Provide the location
address of the meter or communication service.
Section C: Billing Name. A complete copy of the utility
billings with billing name, location, meter number and
account number must be attached. If this information is not
available on the bill, other documentation will need to be
provided. For example, a screenshot of your online utility
account or correspondence from the utility company on
their letterhead with the information needed. Annual utility
usages must be documented. Attach 12 months of billings.
Section D: Fill in All Applicable Blanks. Complete all
applicable information. Any missing information may delay
the processing of your application.
Section E: Summary. Explain how the utility is used.

Example. For telephone service used in rendering public
transportation, the supporting schedule may read 35%
dispatch, 5% sales, 5% marketing, etc. Usage must total
100%.
Section F: Utility Usage Study. Production is eligible for
predominate use exemption. Businesses need to provide the
following information detailing production and non-production
equipment for the meter: (R&D skip to Section G)
• List each piece of equipment connected to the meter
(production and non-production equipment);
• Explain how the equipment is used;
• Provide the power rating of each piece of equipment;
• List the number of hours the equipment is used;
• Provide the total energy consumed for each piece of
equipment for the previous calendar year.
Section G: Utility Usage Study. Research and
Development (R&D) is not eligible for predominate use
exemption. Businesses need to provide the following
information detailing the R&D and non-R&D equipment
usage for the meter:
• List each piece of equipment connected to the meter
(R&D and non-R&D);
• Explain how the equipment is used;
• Provide the power rating of each piece of equipment;
• List the number of hours the equipment is used;
• Provide the total energy consumed for each piece of
equipment for the previous calendar year.
Section H. Certification/Signature. Sign and date the
application. If you are a representative, a Form POA-1 must
be attached. If submitting via DOR’s secure e-service portal
INTIME, an electronic POA (ePOA) must be completed.
The person who completed the utility study must sign and
date the form.
Return the application to:
Indiana Department of Revenue
P.O. Box 935
Indianapolis, IN 46206-0935
For assistance, contact DOR directly via INTIME
messaging at intime.dor.in.gov by selecting “Send a
message” under the “All Actions” tab. Or call customer
service at 317-232-2240.