Contractors Statement Regarding Purchase For Exempt Organization - Illinois

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Customer #
Store #
Account #
STATE OF ILLINOIS
CONTRACTORS STATEMENT REGARDING
PURCHASE FOR EXEMPT ORGANIZATION
Identification of Contract:
Exempt Organization Name
Address
City
ST
Zip
Date of Contract
Exempt Organizations
Illinois Sales Tax Exemption “E” Number
The undersigned herby certifies that the tangible personal property purchase from:
Was purchased for incorporation into the realty of the exempt organization listed above.
Contractor:
SubContractor:
Name
Name
Signature
Signature
Date
Date
Title
Title
Address
Address
City
City
State
Zip
State
Zip
Customer #
Client #
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