Form F0003 - Certificate Of Exemption Page 2

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Multi-state Supplemental
Name of Purchaser
STATE
Reason for Exemption
Identification Number (If Required)
AR
IA
IN
KS
KY
MI
MN
NC
ND
NE
NJ
NV
OH
OK
RI
SD
TN
UT
VT
WA
WV
WY
SSUTA Direct Mail provisions are not in effect for Tennessee.
The following nonmember states will accept this certificate for exemption claims that are valid in their respective state. SSUTA Direct Mail
provisions do not apply in these states.
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
SSTGB Form F0003 Exemption Certificate (2/22/08)

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