Nebraska Resale or Exempt Sale Certificate
for Sales Tax Exemption
Name and Mailing Address of Purchaser
Name and Mailing Address of Seller
Mohawk Network Solutions
Street Address (Do not use PO Box)
Street or Other Mailing Address
30011 Ivy Glenn Dr. #209
Check Type of Certificate
If single purchase is checked, enter the related invoice or purchase order number ______________________________________.
If blanket is checked, this certificate is valid until revoked in writing by the purchaser.
I hereby certify that the purchase, lease, or rental by the above purchaser is exempt from the Nebraska sales tax for the following reason:
Purchase for Resale (Complete Section A.)
Exempt Purchase (Complete Section B.)
Contractor (Complete Section C.)
Section A — Nebraska Resale Certificate
Description of Property or Service Purchased
I hereby certify that the purchase, lease, or rental of ________________________________________________________________from the seller
listed above is exempt from the Nebraska sales tax as a purchase for resale, rental, or lease in the normal course of our business. The property or service
will be resold either in the form or condition in which it was purchased, or as an ingredient or component part of other property or service to be resold.
I further certify that we are engaged in business as a:
Description of Product or Service Sold, Leased, or Rented
Nebraska Sales Tax Permit Number is 01-_________________________________.
If none, state the reason _____________________________________________________________________________________________________,
or Foreign State Sales Tax Number__________________________________________ State __________________________________________.
Section B — Nebraska Exempt Sale Certificate
The basis for this exemption is exemption category ______ (insert appropriate number for the category of exemption described on the reverse side).
If exemption category 2 or 5 is claimed, enter the following information:
Description of Items Purchased
Intended Use of Items Purchased
If exemption category 3 or 4 is claimed, enter your Nebraska Exemption Certificate number. 05 -______________________________
Do not enter your Federal Employer ID Number.
If exemption category 6 is claimed, the seller must enter the following information and sign this form below:
Description of Items Sold
Date of Seller’s Original Purchase
Was tax paid when purchased by seller?
Was item depreciable?
Section C — For Contractors Only
1. Purchase of building materials or fixtures.
As an Option 1 or Option 3 contractor, I hereby certify that the purchase of building materials and fixtures from the seller listed above are exempt
from Nebraska sales tax. My Nebraska Sales or Use Tax Permit Number is: _____________________________________________________.
2. Purchases made by an Option 2 contractor under a Purchasing Agent Appointment on behalf of_________________________
As an Option 2 contractor, I hereby certify that the purchase of building materials and fixtures from the seller listed above is exempt from
Nebraska sales tax pursuant to the attached Purchasing Agent Appointment and Delegation of Authority for Sales and Use Tax, Form 17.
Any purchaser, agent, or other person who completes this certificate for any purchase which is not for resale, lease, or rental in the regular course of the
purchaser’s business, or is not otherwise exempted from sales and use taxes is subject to a penalty of $100 or ten times the tax, whichever amount is larger, for
each instance of presentation and misuse. With regard to a blanket certificate, this penalty applies to each purchase made during the period the blanket certificate
is in effect. Under penalties of law, I declare that I am authorized to sign this certificate, and to the best of my knowledge and belief, it is correct and complete.
Authorized Signature Name (please print)
Do not send this certificate to the Nebraska Department of Revenue. Keep it as part of your records.
Sellers cannot accept incomplete certificates.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Supersedes 6-134-1970 Rev. 3-2009