Uniform Sales & Use Tax Certificate Template - Multijurisdiction - 2009
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4UNIFORM SALES & USE TAX CERTIFICATE—MULTIJURISDICTION
The below-listed states have indicated that this form of certificate is acceptable, subject to the notes on pages 2-4. The issuer and the
recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may
change from time to time.
Issued to Seller:________________________________________________________________________________________
Address: _____________________________________________________________________________________________
I certify that:
is engaged as a registered
Name of Firm (Buyer): ________________________________
Wholesaler
Address: ___________________________________________
Retailer
__________________________________________________
Manufacturer
__________________________________________________
Seller (California)
__________________________________________________
Lessor
(see notes on pages 2-4)
__________________________________________________________
Other (Specify)_____________
and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for
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wholesale, resale, ingredients or components of a new product or service
to be resold, leased, or rented in the normal course of business. We are in
the business of wholesaling, retailing, manufacturing, leasing (renting) the following:
Description of Business: ______________________________________________________________________________________________
General description of tangible property or taxable services to be purchased from the seller: ________________________________________
__________________________________________________________________________________________________________________
State
State Registration, Seller’s Permit, or ID
State
State Registration, Seller’s Permit, or ID
Number of Purchaser
Number of Purchaser
1
16
AL
____________________________________
MO
_____________________________________
17
AR
____________________________________
NE
_____________________________________
2
AZ
____________________________________
NV
_____________________________________
3
CA
____________________________________
NJ
_____________________________________
4
4,18
CO
____________________________________
NM
_____________________________________
5
19
CT
____________________________________
NC
_____________________________________
6
DC
____________________________________
ND
_____________________________________
7
20
FL
OH
_____________________________________
8
21
GA
____________________________________
OK
_____________________________________
4,9
22
HI
____________________________________
PA
_____________________________________
23
ID
____________________________________
RI
_____________________________________
4,10
IL
____________________________________
SC
_____________________________________
24
IA
____________________________________
SD
_____________________________________
KS
____________________________________
TN
_____________________________________
11
25
KY
____________________________________
TX
_____________________________________
12
ME
____________________________________
UT
_____________________________________
13
MD
____________________________________
VT
_____________________________________
14
26
MI
____________________________________
WA
_____________________________________
15
27
MN
____________________________________
WI
_____________________________________
I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or use Tax we
will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall
be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked
by the city or state.
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: _____________________________________________________________________________
Revised 10/22/2009
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