Form St-121.6 - Qualified Empire Zone Enterprise (Qeze) Exempt Purchase Certificate - 2005
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1ST-121.6
New York State Department of Taxation and Finance
New York State Sales and Use Tax
Qualified Empire Zone Enterprise (QEZE)
(5/05)
Exempt Purchase Certificate
To be completed by
the purchaser and
given to the seller
Name of seller
Name of QEZE/purchaser
Street address
Street address
City
State
ZIP code
City
State
ZIP code
QEZE certification number
(issued by the New York State Tax Department)
Single purchase certificate
Mark an X in one:
Blanket purchase certificate
You cannot use this form to purchase motor fuel or diesel motor fuel exempt from tax.
Exempt purchases
(Mark an X in boxes that apply)
A. Tangible personal property or services (other than consumer utility services and motor vehicles). The
property or services will be directly and predominantly (at least 50%) used or consumed by the QEZE in
an empire zone in which the QEZE has qualified for benefits.
B. Consumer utility services (other than telephony and telegraphy, telephone and telegraph services, and
telephone answering services). The services will be directly and exclusively (100%) used or consumed
by the QEZE in an empire zone in which the QEZE has qualified for benefits.
C. Telephony and telegraphy, telephone and telegraph services, and telephone answering services. These
services will be delivered and billed to the QEZE at an address in an empire zone in which the QEZE
has qualified for benefits.
D. Motor vehicle to be used predominantly (at least 50%) in an empire zone in which the QEZE has
qualified for benefits. (See below and the back for further information.)
E. Tangible personal property related to a qualifying motor vehicle (as described in box D above).
Purchases made with this certificate are exempt from the New York
It is the responsibility of the seller to determine whether an
State sales and use tax rate and from the
3
/
% tax imposed in the
exemption from local tax applies. See Publication 718-Q, Local
8
Metropolitan Commuter Transportation District (MCTD). Purchases
Sales and Use Tax Rates on Sales to a Qualified Empire Zone
(other than motor vehicles) are exempt from the local sales and use
Enterprise (QEZE), for a listing of the local jurisdictions that enacted
tax only if the purchaser takes possession of the property or uses
the QEZE exemptions and the rates in effect in those localities that
the service in a locality that has enacted the QEZE exemptions.
did not enact the exemption. (See back for further information.)
Purchases of motor vehicles are exempt from the local tax if the
locality in which the QEZE will predominantly use the vehicle has
enacted the QEZE exemptions, regardless of where delivery takes
place.
Certification. I certify that the above statements are true and correct. I make these statements with the knowledge that knowingly making a
false or fraudulent statement on this document is a misdemeanor under section 1817 of the Tax Law and section 210.45 of the Penal Law,
punishable by imprisonment for up to a year and a fine of up to $10,000 for an individual or $20,000 for a corporation. I understand that the
Tax Department is authorized to investigate the validity of the exemption claimed or the accuracy of any information entered on this form.
Signature of purchaser or purchaser’s representative
Date
(give title and relationship)
Type or print the name that appears in the signature box
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