Sales And Or Trasales And/or Transient Guest Tax Exemption Certificate Form For Lodging
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2KANSAS DEPARTMENT OF REVENUE
SALES AND/OR TRANSIENT GUEST TAX EXEMPTION CERTIFICATE FOR LODGING
The undersigned purchaser certifies that all information provided below is true and correct, and that the tangible personal property
or services purchased from the seller is exempt from Kansas sales tax or Kansas transient guest tax for the reason(s) stated below
(check applicable box(es)). The undersigned understands and agrees that if the tangible personal property or services are used
other than as stated, or for any other purpose that is not exempt from sales or transient guest tax, the undersigned purchaser
becomes liable for the tax.
Seller (hotel) Name: ___________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street, P.O. Box or Rural Route
City
State
Zip Code
Guest Name: _____________________________________________________________ Room Number: _____________
Address: ____________________________________________________________________________________________
Street, P.O. Box or Rural Route
City
State
Zip Code
Arrival Date: ______ ______ ______
Anticipated Departure Date: ______ ______ ______
Hotel Guest Signature _________________________________________________________________________________
‰
State Exemption from Kansas Sales Tax
(Tax exempt entity shall present KDOR-issued tax-exempt entity sales tax exemption
certificate showing state-issued exempt organization ID number; Form PR-78SSTA; or Designated or Generic Exemption Certificate,
ST-28.)
Tax Exempt Entity Name: _______________________________________________________________________________
Address: ____________________________________________________________________________________________
Street, P.O. Box or Rural Route
City
State
Zip Code
Kansas Exempt Organization ID Number: _______________________________ Expiration Date: ______ ______ ______
‰
Federal Exemption from Kansas Sales Tax.
I certify that I am on official federal government business and the purpose of
my stay is in conjunction with my performance of official duties as an officer or employee of the federal entity listed below.
‰
Federal Exemption from Transient Guest Tax
Tax Exempt Federal Entity Name: ________________________________________________________________________
Address: ____________________________________________________________________________________________
Street, P.O. Box or Rural Route
City
State
Zip Code
If you are paying with a GSA SmartPay Card, enter the 6
th
digit of the credit card number here: ________________________
(Note: The digit must be a 0, 6, 7, 8 or 9 to qualify for exemption from Transient Guest Tax.)
‰
Direct Purchase
(Complete on state sales tax and federal transient guest tax exemptions.)
Complete this section as evidence of direct purchase for transient guest tax exemptions granted to the federal government. This
section can also be completed to document direct purchase for sales tax exemptions granted by the state of Kansas to tax-exempt
entities.
_____ Credit Card
Name on credit card ______________________________________
Last 4 digits: _____________
Must be name of exempt organization
_____ Direct Bill
Billing Account Name/Number ________________________________________________________
_____ Check
Check from ___________________________________________ Check Number: _____________
THIS CERTIFICATE MUST BE COMPLETED IN ITS ENTIRETY.
P
.
LEASE REFER TO THE INSTRUCTIONS FOR USE OF THIS CERTIFICATE ON THE REVERSE
ST-28H (2/14)
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