Iowa Sales Tax Exemption Certificate Form
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1Iowa Department of Revenue
Iowa Sales Tax Exemption Certificate
https://tax.iowa.gov
Energy Used in Processing or Agriculture
This document is to be completed by a purchaser to claim exemption from sales/use tax.
This form must be provided to the seller of the energy used in processing or agriculture to exempt future
purchases from sales tax. Certificates are valid for up to three years.
For Prior Period: To obtain a refund of sales tax previously paid on energy used for processing or
agriculture, use form IA 843. Worksheets and examples for completing an energy study can be found on the
sales tax forms page of our
website at https://tax.iowa.gov.
An energy study must be attached to the IA
843 in order to receive a refund.
Purchaser Name: ___________________________
Seller Name: _____________________________
Address: __________________________________
Address: _________________________________
City, State, ZIP: ____________________________
City, State, Zip: ____________________________
General Nature of Business: ____________________________________________________________
Telephone Number: _________________________
□
□
Fuel Purchased:
Electricity
Gas
□
Other
, specify:
___________________________________________
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□
□
Reason for Exemption:
Grain Drying
Raising Livestock
Generating Electricity
□
□
□
Data Center
Processing
Manufacturing
□
Other
, specify: _____________________________________________
Effective Date of the Exemption Certificate: _____ / ____ / ___
Meter Number: __________________________________
Utility Account Number: ___________________________
+
=
Exempt % _____
Taxable % _____
100%
Under penalties of perjury, I swear or affirm that the information on and attached to this form is true
and correct as to every material matter.
Authorized Signature of Owner, Partner, or Corporate Officer:
Title:
Date:
31-113a (07/02/15)
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