Form 72-15-06 "Affidavit for Utility Exemption" - Mississippi

What Is Form 72-15-06?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Mississippi Department of Revenue;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 72-15-06 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

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Download Form 72-15-06 "Affidavit for Utility Exemption" - Mississippi

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AFFIDAVIT FOR
UTILITY EXEMPTION
Form 72-15-06
_________________________________________________
STATE OF MISSISSIPPI, COUNTY OF
BEFORE ME, the undersigned authority, on
(County of Notary Public)
___________________________________________
__________________________________________
this day personally appeared
of
,
(Organization Representative’s Name)
(Organization Name)
who after being by me first duly sworn, on oath deposed and said:
(Choose only ONE of the following entities)
Under the penalty of perjury, I hereby certify that the organization named above is a
 Manufacturer. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel sold to the
organization named above will be utilized directly in the organization’s commercial operations and meets the criteria provided for in Miss.
Code Ann. § 27-65-107(f).
 Custom Processor. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel sold to the
organization named above will be utilized directly in the organization’s commercial operations and meets the criteria provided for in Miss.
Code Ann. § 27-65-107(f).
 Technology Intensive Enterprise. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other
fuel sold to the organization named above will be utilized directly in the organization’s commercial operations and meets the criteria
provided for in Miss. Code Ann. § 27-65-17(1)(f).
 Public Service Company. I further certify that the purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel
sold to the organization named above will be utilized directly in the organization’s commercial operations and will be used for industrial
purposes which includes that used to generate electricity, to operate an electrical distribution or transmission system, to operate pipeline
compressors or pumping stations or to operate railroad locomotives. See Miss. Code Ann. § 27-65-107(f).
 Agricultural Producer or Processor. I further certify that the purchases of electricity, current, power, natural gas, liquefied petroleum gas
or other fuel sold will be used directly by the producer or processor named above in the production of poultry products, livestock products,
domesticated fish products, marine agriculture products, milk products, the production of plants or food by commercial horticulturists, the
processing of poultry and livestock feed and the irrigation of farm crops. See Miss. Code Ann. § 27-65-107(g).
 Fisherman, Shrimper or Oysterman. See Miss. Code Ann. § 27-65-107(h).
Furthermore, I certify and agree that if the above-named organization or I fail to adhere to the selected provision provided above, that the above-
named organization and/or I will pay to the Mississippi Department of Revenue the difference between the rate paid to vendors when making
eligible purchases as described herein and the regular retail rate of sales tax. Moreover, I acknowledge that failure to adhere to the provisions
provided herein will result in tax being due and payable at the seven percent (7%) retail rate, a fifty percent (50%) fraud penalty and the
applicable rate of interest per month provided in Miss. Code Ann. § 27-65-39, from the date of purchase until this additional tax is paid to the
Mississippi Department of Revenue. Finally, I acknowledge that if the organization ceases operating as the selected eligible organization I will
notify the dealer so that applicable sales tax rates may be charged on future purchases, and that failure to notify the dealer will result in liability to
the organization for the tax due, including penalty and interest, as stated above.
Visit our website at www.dor.ms.gov for more information concerning each exemption.
WITNESS MY SIGNATURE, this the ______ day of __________________, 20_____.
(Representative’s Printed Name)
(Representative’s Signature)
(Organization’s Mailing Street Address, City, State, Zip Code)
Work Phone #
(
)
-
Alt. Phone #
(
)
-
Email
NOTARY PUBLIC ACKNOWLEDGMENT
STATE OF MISSISSIPPI, COUNTY OF ________________________________________.
(County of Notary Public)
Personally appeared before me, the undersigned authority in and for the said county and state, on this ______ day of ____________,
____________________________________________
20______, within my jurisdiction, the within named
, who acknowledged that he/she is the
Representative’s Name
___________________________________________
of _________________________________________ and that in said representative capacity
Representative’s Relationship/Position
Organization’s Name
he/she executed the above and foregoing instrument after have been duly authorized to do so.
Notary Public Name:
[ Place Seal Here ]
Signature:
Commission Expiration:
Sales and Use Tax Bureau
P.O. Box 1033
Jackson, MS 39215
www.dor.ms.gov
Phone: 601-923-7015
Fax: 601-923-7034
AFFIDAVIT FOR
UTILITY EXEMPTION
Form 72-15-06
_________________________________________________
STATE OF MISSISSIPPI, COUNTY OF
BEFORE ME, the undersigned authority, on
(County of Notary Public)
___________________________________________
__________________________________________
this day personally appeared
of
,
(Organization Representative’s Name)
(Organization Name)
who after being by me first duly sworn, on oath deposed and said:
(Choose only ONE of the following entities)
Under the penalty of perjury, I hereby certify that the organization named above is a
 Manufacturer. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel sold to the
organization named above will be utilized directly in the organization’s commercial operations and meets the criteria provided for in Miss.
Code Ann. § 27-65-107(f).
 Custom Processor. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel sold to the
organization named above will be utilized directly in the organization’s commercial operations and meets the criteria provided for in Miss.
Code Ann. § 27-65-107(f).
 Technology Intensive Enterprise. I further certify that purchases of electricity, current, power, natural gas, liquefied petroleum gas or other
fuel sold to the organization named above will be utilized directly in the organization’s commercial operations and meets the criteria
provided for in Miss. Code Ann. § 27-65-17(1)(f).
 Public Service Company. I further certify that the purchases of electricity, current, power, natural gas, liquefied petroleum gas or other fuel
sold to the organization named above will be utilized directly in the organization’s commercial operations and will be used for industrial
purposes which includes that used to generate electricity, to operate an electrical distribution or transmission system, to operate pipeline
compressors or pumping stations or to operate railroad locomotives. See Miss. Code Ann. § 27-65-107(f).
 Agricultural Producer or Processor. I further certify that the purchases of electricity, current, power, natural gas, liquefied petroleum gas
or other fuel sold will be used directly by the producer or processor named above in the production of poultry products, livestock products,
domesticated fish products, marine agriculture products, milk products, the production of plants or food by commercial horticulturists, the
processing of poultry and livestock feed and the irrigation of farm crops. See Miss. Code Ann. § 27-65-107(g).
 Fisherman, Shrimper or Oysterman. See Miss. Code Ann. § 27-65-107(h).
Furthermore, I certify and agree that if the above-named organization or I fail to adhere to the selected provision provided above, that the above-
named organization and/or I will pay to the Mississippi Department of Revenue the difference between the rate paid to vendors when making
eligible purchases as described herein and the regular retail rate of sales tax. Moreover, I acknowledge that failure to adhere to the provisions
provided herein will result in tax being due and payable at the seven percent (7%) retail rate, a fifty percent (50%) fraud penalty and the
applicable rate of interest per month provided in Miss. Code Ann. § 27-65-39, from the date of purchase until this additional tax is paid to the
Mississippi Department of Revenue. Finally, I acknowledge that if the organization ceases operating as the selected eligible organization I will
notify the dealer so that applicable sales tax rates may be charged on future purchases, and that failure to notify the dealer will result in liability to
the organization for the tax due, including penalty and interest, as stated above.
Visit our website at www.dor.ms.gov for more information concerning each exemption.
WITNESS MY SIGNATURE, this the ______ day of __________________, 20_____.
(Representative’s Printed Name)
(Representative’s Signature)
(Organization’s Mailing Street Address, City, State, Zip Code)
Work Phone #
(
)
-
Alt. Phone #
(
)
-
Email
NOTARY PUBLIC ACKNOWLEDGMENT
STATE OF MISSISSIPPI, COUNTY OF ________________________________________.
(County of Notary Public)
Personally appeared before me, the undersigned authority in and for the said county and state, on this ______ day of ____________,
____________________________________________
20______, within my jurisdiction, the within named
, who acknowledged that he/she is the
Representative’s Name
___________________________________________
of _________________________________________ and that in said representative capacity
Representative’s Relationship/Position
Organization’s Name
he/she executed the above and foregoing instrument after have been duly authorized to do so.
Notary Public Name:
[ Place Seal Here ]
Signature:
Commission Expiration:
Sales and Use Tax Bureau
P.O. Box 1033
Jackson, MS 39215
www.dor.ms.gov
Phone: 601-923-7015
Fax: 601-923-7034