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Form As 2916.1 - Certificate For Exempt Purchases And For Services Subject To The 4% Special-Sut Page 2

Page 2

Form AS 2916.1 Rev. Oct 9 15

PART III

PURCHASER'S CERTIFICATION

I hereby declare under penalties of perjury that this certificate has been examined by me, and that to the best of my knowledge and belief all the information

provided herein is true, correct and complete. I also certify that:

I am entitled to claim an exemption as indicated on line 5 of Part II, or I am duly authorized to represent the purchaser in the signature of this Certificate for Exempt

Purchases and for Services Subject to the 4% Special-SUT.

I will only use this certificate to buy taxable items or services for which I am entitled to claim an exemption or exclusion or to document that I am subject to the

4% Special-SUT.

If I acquire taxable items, but I use or consume them for non-exempt purposes in Puerto Rico, I will report and pay the use tax directly to the Department of

the Treasury.

That the Exemption Certificate, Reseller Certificate, Eligible Reseller Certificate or any other Waiver evidencing the exemption is in force at the date of the

purchase transaction.

Purchaser's name

Purchaser's signature

Address

Telephone

Municipality

State

Zip Code

Retention: Six (6) years.