Form St-5 Sales Tax Exempt Purchaser Certificate
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1
2Rev. 6/09
Form ST-5
Massachusetts
Sales Tax Exempt
Department of
Purchaser Certificate
Revenue
Part 1. Exempt taxpayer information.
To be completed by exempt government or 501(c)(3) organization.
Name
Address
City
State
Zip
Exemption number
Issue date
Date of expiration of certificate
Certification is hereby made that the organization named above is an exempt purchaser under Massachusetts General Laws, Chapter 64H, sections 6(d)
or 6(e). All purchases of tangible personal property or services by this organization are exempt from taxation under said chapter to the extent that such
property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or
any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation.
Signature
Title
Date
Warning: Willful misuse of this certificate may result in criminal tax evasion sanctions of up to one year in prison and $10,000 ($50,000 for
corporations) in fines.
Part 2. Agent information.
To be completed by agent of exempt government or 501(c)(3) organization.
Name of agent’s organization
Address
City
State
Zip
Agent’s name
Address
City
State
Zip
I certify that in making this purchase, I am acting as an agent for the exempt organization named above (select one):
Government organization (local public school, city/town government, state agency, etc.).
Attach Form ST-2, if available. If Form ST-2 is not available, enter exemption number, if known:
501(c)(3) organization (parochial school, Scout troop, etc.). Form ST-2 must be attached.
Signature
Title
Date
Part 3. Vendor information
Vendor’s name
Mohawk Network Solutions
Check applicable box:
Single purchase certificate (attach detailed receipts or complete Part 4, on reverse)
Blanket certificate
This form is approved by the Commissioner of Revenue and may be reproduced.
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