Form St-13 Small Business Energy Exemption Certificate printable pdf download

Form St-13 Small Business Energy Exemption Certificate

Rev. 11/96

Massachusetts

Form ST-13

Department of

Small Business Energy Exemption Certificate

Revenue

Vendor’s name

Address

City/Town

State

Zip code

I hereby certify that the energy described below is purchased by a business with five or fewer employees exempt from sales tax under MGL Ch. 64H,

sec. 6(qq), on its purchases of the following checked item. This certification does not entitle the business to any exemption from tax on purchases of tan-

gible personal property as defined in MGL Ch. 64H, sec. 1, except gas, steam, electricity or heating fuel.

Description of energy being purchased (check one):

Number of employees

Gas

Steam

Electricity

Heating Fuel

Full liability is hereby assumed for the payment of any use tax due in the event that the business is not a qualified small business with five or fewer em-

ployees. This certificate shall be considered a part of each order unless revoked in writing. All vendor purchase orders under this certificate shall clearly

state that they represent purchases by exempt small businesses.

Signed under the penalties of perjury.

Signature

Title

Name of company

Federal Identification number

Address

City/Town

State

Zip code

Date

Type of certificate (check one):