Purchase Exemption Certificate Form printable pdf download

Purchase Exemption Certificate Form

Exemption Number

Name of Exempt Institution

Check Applicable Block

PURCHASE EXEMPTION

Important—Certificate not

Blanket

valid unless completed.

CERTIFICATE

Single Purchase

I hereby certify that ___________________________________ is a Kentucky resident, nonprofit educational, charitable or

Name of Exempt Institution

religious institution, or Kentucky historical site, located at ___________________________, Kentucky and that the tangible

personal property or services to be purchased from_____________________________________________________________________

Name of Vendor

_____________________________________________________________________________________________________________________

Address

will be used solely within the exempt function of a charitable, educational or religious institution, or historical site.

Description of property to be purchased:___________________________________________________________________________

________________________________________________________________________________________________________________

In the event that the property purchased is not used for an exempt purpose, it is understood that I am required to pay the tax

measured by the purchase price of the property.

Any official or employee who uses this certificate to make tax-free purchases for his own personal use or that of any other

person will be subject to the penalties provided in KRS 139.990 and other applicable laws.

Under penalties of perjury, I swear or affirm that the information on this certificate is true and correct as to every material

matter.

Authorized Signature

Title

CAUTION TO SELLER: This certificate cannot be issued or used in

Date

any way by a construction contractor to purchase property to be

used in fulfilling a contract with an exempt institution. Sellers

accepting certificates for such purchases will be held liable for the

DEPARTMENT OF REVENUE

sales or use tax.

Frankfort, Kentucky 40620

51A126 (8-04)

Purchase Exemption Certificate Form