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Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax - New York State Department Of Taxation And Finance - New York Page 4

Page 4 of 4 ST-140 (2009)

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, Article 37, 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

(if other than purchaser)

Preparer’s address

Preparer’s signature

Preparer’s telephone number

(if other than purchaser)

(

)

Mail this return and remittance to:

NYS TAX DEPARTMENT

SALES TAX DESK AUDIT — CASUAL SALES UNIT

W A HARRIMAN CAMPUS

ALBANY NY 12227

Private delivery services

If you choose, you may use a private delivery service, instead of the U.S. Postal Service, to mail in your return and tax payment. However, if,

at a later date, you need to establish the date you filed your return or paid your tax, you cannot use the date recorded by a private delivery

service unless you used a delivery service that has been designated by the U.S. Secretary of the Treasury or the Commissioner of Taxation

and Finance. (Currently designated delivery services are listed in Publication 55, Designated Private Delivery Services. See Need help? on

page 2 of Form ST-140-I, for information on obtaining forms and publications.) If you have used a designated private delivery service and

need to establish the date you filed your return, contact that private delivery service for instructions on how to obtain written proof of the date

your return was given to the delivery service for delivery.

4400400090094

Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax - New York State Department Of Taxation And Finance - New York Page 4

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