Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax - 2016 Page 4
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4Page 4 of 4 ST-140 (2016)
Certification: I certify that the above statements are true and correct, and I make these statements with the knowledge that willfully issuing a false
or fraudulent document with the intent to evade tax may constitute a felony under New York State Tax Law, punishable by a substantial fine and a
possible jail sentence. I also understand that the Tax Department is authorized to investigate the validity or the accuracy of any information entered on
this document.
Purchaser’s signature
Date
Telephone number for purchaser
/
/
(
)
Printed name of preparer
Preparer’s PTIN
(if other than purchaser)
Preparer’s address
Preparer’s NYTPRIN
Excl. code
Preparer’s signature
Preparer’s telephone number
(if other than purchaser)
(
)
44000400160094
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