Form St-104 - Agricultural Exemption Certificate - 2003
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1Indiana Department of Revenue
Form ST-104
Agricultural Exemption Certificate
State Form # 12707 (6-03)
(Single Purchase)
Article Purchased
Purchase Price
How Used
(You must have at least one of the numbers below for this
Purchased by
certificate to be valid.)
Date
Social Security #
Address
Taxpayer ID #
City and Zip Code
Federal ID #
I hereby certify under the penalties of perjury that the personal property purchased by the use of this exemption certificate will be
directly used in the production of agricultural products for resale.
Signature
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Parent category: Financial