Form R-1085 - Farmer Or Agricultural Facility Certification Application - Louisiana Department Of Revenue

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R-1085 (10/09)
Farmer or Agricultural Facility
Certification Application
Louisiana Revised Statute 47:305.25(A)
Louisiana Department of Revenue
Special Programs Division
P.O. Box 66362
Baton Rouge, LA 70896-6362
Date of Application: _____________________
NOTE: This application must be submitted with a copy of the applicant’s most recent federal income tax return
schedule used for reporting farm income.
PLEASE PRINT OR TYPE.
Louisiana Sales Tax Number (if applicable)
Check One
■
■
Farmer
Agricultural Facility
Social Security Number
Telephone Number
Legal Name
Trade Name
(if applicable)
Mailing Address
City
State
ZIP
Location Address
City
State
ZIP
(if different than above)
Please list crops produced or sold:
NAICS code: Please choose a North American Industry Classification System (NAICS) code which best describes your predominant
farming activity. NAICS codes associated with farming activities are listed on the back of this application.
NAICS CODE: ____________________________________
Under the penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it is true,
correct and complete.
Application Authorization
Name
Title
Signature of Applicant
Date
(mm/dd/yyyy)
X
FOR DEPARTMENT USE ONLY
Department Representative
Certification Expiration Date
■
Approved
Effective Date
■
Disapproved
The approved original exemption certificate is valid for three years from the date of approval by LDR and must be retained by the applicant.
Copies of the approved exemption certificate must be given to vendors to document exemption from state sales tax. Any applicant who
fraudulently signs this certificate is subject to all the penalties provided for by Title 47 of the Louisiana Revised Statutes and collection will
be pursued against the purchaser for any taxes, penalties and interest due.

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