Household Hazardous Materials Permit Appllication



This form must be completed and returned

Please the read the enclosed materials before completing.

HOUSEHOLD HAZARDOUS MATERIALS PERMIT APPLICATION

Complete this application if you sell Household Hazardous Materials on a retail basis. Please read the instructions on the other side of this form.

DO NOT REMOVE THIS LABEL CORRECT ADDRESS HERE

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THE PERMIT FEE IS $25.00 PER LOCATION**

** Manufacturers or distributors that utilize independent agents to sell person to person at a consumer's home may purchase one permit at a fee of $25 for the first $3 million in sales of household hazardous materials, plus $100 for each subsequent increment of $3 million in sales of household hazardous materials (see the enclosed HHM Permit Information sheet for more details).

Complete the following and make check payable to Treasurer, State of Iowa.

Sales Tax Permit #: ________________________ Fee Remitted: _________________________

Name and title of owner, manager or officer (for example, John Smith, treasurer) Please Print:

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Signature: _____________________________________________________________________

Title: ___________________________________ Date: ________________________________

AFFIDAVIT

Complete affidavit only if you DO NOT sell Household Hazardous Materials

I attest under penalty of law that as owner or manager of the business named above, I DO NOT offer any Household Hazardous Materials for retail sale (see enclosed list).

Sales Tax Permit #: ______________________________________________________________

Name and title of owner, manager, or officer (for example, John Smith, treasurer) Please Print:

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Signature: _________________________________ Phone number: _______________________

Title: __________________________________________ Date: __________________________

Reason for Exemption: ______________________________________________________________________________

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Complete the permit application or affidavit and mail this entire page to the Iowa Department of Revenue and Finance, P. O. Box 10455, Des Moines, Iowa 50306-0455.

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