Application For Exemption Certificate

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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

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