Form Dr 0563 - Sales Tax Exemption Certificate Multi - Jurisdiction
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1DR 0563 (08/30/13)
*130563==19999*
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0013
Sales Tax Exemption Certificate
Customer #
Multi - Jurisdiction
See page 2 for instructions
Last Name or Business Name
First Name
Middle Initial
Address
City
State
ZIP
I Certify That
Name of Firm (Buyer)
Address
City
State
ZIP
Qualifies As (Check each applicable item)
Wholesaler
Retailer
Manufacturer
Charitable or Religious
Political Subdivision or Governmental Agency
Other (Specify)
If Other, specify here
1) and is registered with the below listed states and cities within which your firm would deliver purchases to us
which are for resale or lease by us in the normal course of our business which is
or
2) that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
Political Subdivision or Governmental Agency
Charitable or Religious
Otherwise Exempt By Statute (Specify)
If Otherwise Exempt By Statue, specify here
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
If the list of states and cities is more than six(6), attach a list to this certificate.
I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sale or
Use Tax we will pay the tax due direct to proper taxing authority when state law so provides or inform the seller for added
tax billing. This certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and
shall be called until canceled by us in writing or revoked by the city or state.
General Description of products to be purchased from seller
Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.
Authorized Signature (owner, Partner or Corporate Officer)
Title
Date
(MM/DD/YY)
Customer #
Client #
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