Streamlined Sales And Use Tax Agreement
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1
2Streamlined Sales and Use Tax Agreement
Certificate of Exemption
This is a multi-state form. Not all states allow all exemptions listed on this form. Purchasers are responsible for knowing if they qualify to
claim exemption from tax in the state that would otherwise be due tax on this sale. The seller may be required to provide this exemption
certificate (or the data elements required on the form) to a state that would otherwise be due tax on this sale.
The purchaser will be held liable for any tax and interest, and possibly civil and criminal penalties imposed by the member state, if the
purchaser is not eligible to claim this exemption. A seller may not accept a certificate of exemption for an entity-based exemption on a sale
made at a location operated by the seller within the designated state if the state does not allow such an entity-based exemption.
1.
D
Check if you are attaching the Multi-state Supplemental form.
DD
If not, enter the two-letter postal abbreviation for the state under whose laws you are claiming exemption.
2.
D
Check if this certificate is for a single purchase and enter the related invoice/purchase order # _ _ _ _ _ _ _ _ _ _ _ _ _ _
3.
Please rint
Name of purchaser
Business Address
Purchaser's Tax ID Number
City
State oflssue
State
Zip Code
Country of Issue
Ifno Tax
ID
Number
I
FEIN
I
Driver's License Number/State Issued JD Number
I
Foreign diplomat number
Enter one of the foJiowing:
I
I
I
__________ L _ _ _ _ _ _ _ LI -"S=ta=te~of,._I' " "s""su""' e "": _ __, _ N-' - ' u "' " m' " "b"-' e "-r _ _ _ _ _ _ _ _ _ _ _ _ .__ _ _ _ _ _ _ _ _
Name of seJier from whom you are purchasing, leasing or renting
Se Iler' s address
4.
Type of business. Circle the number that describes your business
01
02
03
04
05
06
07
08
09
10
Accommodation and food services
Agricultural, forestry, fishing, hunting
Construction
Finance and insurance
Infonnation, publishing and communications
Manufacturing
Mining
Real estate
Rental and leasing
Retail trade
City
11
12
13
14
15
16
17
18
19
20
State
Transportation and warehousing
Utilities
Wholesale trade
Business services
Professional services
Education and health-care services
Nonprofit organization
Government
Not a business
Zip code
Other
(explain) _ _ _ _ _ _ _ _ _ _ _
5,
Reason for exemption. Circle the letter that identifies the reason for the exemption.
A
B
C
D
E
F
G
Federal government
(depa11ment)
- - - - - - - -
St ate or local government
(name) _ _ _ _ _ _ _ _
Tribal government
(name) _ _ _ _ _ _ _ _ _ _ _
Foreign diplomat# _ _ _ _ _ _ _ _ _ _ _ _ _
Charitable organization# _ _ _ _ _ _ _ _ _ _ _ _
Religious or educational organization #
Resale#
- - - - - -
H
I
J
K
L
Agricultural production# _ _ _ _ _ _ _ _ _ _
Industrial production/manufacturing # _ _ _ _ _
Direct pay permit# _ _ _ _ _ _ _ _ _ _ _ _
Direct mail# _ _ _ _ _ _ _ _ _ _ _ _ _ _
Other
(explain) _ _ _ _ _ _ _ _ _ _ _ _ _
6.
Sign here./ declare that the infonnation on this certificate
is
correct and complete to the best ofmy knov.-/edge and belie(
Signature of Authorized Purchaser
Print Name Here
Title
Date
SSTGB Form F0003 Exemption Certificate
(5/10/11)
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