Form Dr-97 - Suggested Format For Blanket Exemption Certificate Based On Property'S Use


Suggested Format for Blanket Exemption
R. 05/04
Certificate Based on Property’s Use
The Department of Revenue does not supply a Blanket Certificate of Exemption form. We do provide this suggested
format that you may use in accordance with Rule 12A-1.038, Florida Administrative Code (F.A.C.). Generic certificates are
available at your local office supply store for a nominal fee. If you prefer, your printer can prepare a certificate to suit your
particular needs as long as it contains the essential information set out below.
Suggested Format Blanket Exemption Certificate
In Accordance with Rule 12A-1.038, F.A.C.
This is to certify that the tangible personal property purchased, leased, licensed, or rented; or services purchased on or
after_______________(date) from _________________________________________(selling dealer’s business name) is
purchased, leased, licensed, or rented for the following purpose as checked in the space provided below. Note: This is not
intended to be an exhaustive list.
Materials, containers, labels, sacks, bags, or similar
Educational materials, such as glue, paper, paints,
items intended to accompany a product for sale at
crayons, unique craft items, scissors, books, and
other than retail, as provided in section 212.02(14)(c),
educational toys, purchased by child care facilities
Florida Statutes (F.S.), by persons who are not
outlined in s. 402.305, F.S., that hold a current
required to be registered under s. 212.18(3), F.S.
license under s. 402.308, F.S., hold a current Gold
Seal Qualifty Care designation as provided in s.
Incorporation into items of tangible personal property
402.281, F.S., and provide employees with basic
manufactured, produced, compounded, processed,
health insurance as defined in s. 627.6699(12), F.S.,
or fabricated for one’s own use, as provided in Rule
as provided in s. 212.08(5)(m), F.S.
12A-1.043, F.A.C.
Motor vehicle rented or leased by a dealer who will
Printing of a publication exempt under the provisions
provide the motor vehicle at no charge to a person
of s. 212.08(7)(w), F.S.
whose motor vehicle is being repaired, adjusted, or
Items, such as paper and ink, that will be
serviced by dealer, as provided in
incorporated into and become a component part of a
s. 212.0601(4), F.S.
publication exempt under the provisions of
Other (include description and statutory citation):
s. 212.08(7)(w), F.S.
I understand that if I use the property or service for any nonexempt purpose, I must pay tax on the purchase or
lease price of the taxable property or service directly to the Department of Revenue.
I understand that if I fraudulently issue this certificate to evade the payment of sales tax, I will be liable for
payment of the sales tax plus a penalty of 200 percent of the tax and may be subject to conviction of a third
degree felony.
The exemption specified by the purchaser may be verified by calling 1-800-352-3671.
Purchaser’s name: _____________________________________________________________________________
Purchaser’s address: ____________________________________________________________________________
Name and title of purchaser’s authorized representative: _________________________________________________
By: ___________________________________________________________________________________________
(Signature of purchaser or authorized representative)
Title: _________________________________________________________ Date: __________________________
(Title – only if purchased by an authorized representative of a business entity)
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Parent category: Financial