Buyers' Certificate Of Tax Exempt Export Carbonated Beverage Syrup Form - Washington State Department Of Revenue

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B
’ C
T
E
UYERS
ERTIFICATE OF
AX
XEMPT
E
C
B
S
XPORT
ARBONATED
EVERAGE
YRUP
(C
82.64 RCW
WAC 458-20-255)
HAPTER
AND
I certify that I purchased the carbonated beverage syrups listed below, from (seller)____________
__________________, which are for export outside Washington State. I will become liable for
and pay any carbonated beverage syrup tax due on all or any part of such products used or sold in
Washington State. This certificate is given with full knowledge of and subject to the legally
prescribed penalties for fraud and tax evasion.
Washington State Tax Registration No. (If applicable)
Legal Name
Trade Name (If different)
Date
Authorized Signature
Title
S
P
YRUPS
URCHASED
T
V
YPE
OLUME
S
P
R
T
F
F
Y
R
ELLER
LEASE
ETAIN
HIS
ORM
OR
OUR
ECORDS
For tax assistance, visit or call 1-800-647-7706. To inquire about the availability of this document in an
alternate format for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
REV 26 0015 (06/17/04)

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