Office:
St. John the Baptist Parish
1704 Chantilly Dr. Suite 101
LaPlace, LA 70068
Sales
Use Tax Office
and
Mailing:
January 15, 2013
P.O. Box 2066
LaPlace, LA 70069-2066
Contact:
APPLICATION FOR EXEMPTION CERTIFICATE
PH: 985-359-6600
FX: 985-359-6602
Email:
Web:
St. John Sales Tax Account#___________ Louisiana Sales Tax Account#_________________ Federal ID #________________
Taxpayer Name: ___________________________________________ Telephone:___________________________________
Business Legal Name: ___________________________________ Business Trade Name: ______________________________
Mailing Address: ______________________________________________________ Zip Code: ______ NAICS#_____________
Physical Address: ______________________________________________________ Zip Code: ______
Nature of Business:______________________________________________________________________________________
Purpose of Request for Exemption Certificate: ________________________________________________________________
______________________________________________________________________________________________________
ACKNOWLEDGMENT
I, ______________________________________ acting in an authorized capacity for_____________________________________
do hereby certify that the information contained herein is true and correct to the best of my knowledge and that the certificate
requested will be solely for the purpose(s) specified in this application. Use of this certificate for any purpose other made known
in this application shall subject applicant to full penalties under the law of this state and local ordinances.
Signed:___________________________________
Date: _____________________________________
FOR OFFICE USE ONLY:
Received: _________________________________
Request: _______ Granted
_______ Denied
Expiration Date: ____________________________
If denied, give reason: ________________________________________________________________________________________
___________________________________________________________________________________________________________
Retailer: _______ Manufacturer: _______ Rental/Lease:_______ Other: _______
Signed:________________________________________
Sales and Use Tax Department