Form Pp005a - Prepaid Sales Tax Exemption Certificate - Indiana Department Of Revenue
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INDIANA DEPARTMENT OF REVENUE
PP005A
PREPAID SALES TAX EXEMPTION CERTIFICATE
(MAY NOT BE USED FOR ANY OTHER TYPE OF EXEMPTION)
Name ________________________________________Prepaid Tax Number ________________________
Address _____________________________________________________
Date ___________________
Indicate type of purchase:
BLANKET
SINGLE PURCHASE
I hereby certify under penalties of perjury that the gasoline purchased is exempt under I.C. 6-2.5-7
and use of this exemption certificate is limited to a sale between Qualified Distributors .
Signature ___________________________________
Title _____________________________________
FOR USE BY QUALIFIED DISTRIBUTORS ONLY
Form
INDIANA DEPARTMENT OF REVENUE
PP005A
PREPAID SALES TAX EXEMPTION CERTIFICATE
(MAY NOT BE USED FOR ANY OTHER TYPE OF EXEMPTION)
Name ________________________________________Prepaid Tax Number ________________________
Address _____________________________________________________
Date ___________________
Indicate type of purchase:
BLANKET
SINGLE PURCHASE
I hereby certify under penalties of perjury that the gasoline purchased is exempt under I.C. 6-2.5-7
and use of this exemption certificate is limited to a sale between Qualified Distributors .
Signature ___________________________________
Title _____________________________________
FOR USE BY QUALIFIED DISTRIBUTORS ONLY
Form
INDIANA DEPARTMENT OF REVENUE
PP005A
PREPAID SALES TAX EXEMPTION CERTIFICATE
(MAY NOT BE USED FOR ANY OTHER TYPE OF EXEMPTION)
Name ________________________________________Prepaid Tax Number ________________________
Address _____________________________________________________
Date ___________________
Indicate type of purchase:
BLANKET
SINGLE PURCHASE
I hereby certify under penalties of perjury that the gasoline purchased is exempt under I.C. 6-2.5-7
and use of this exemption certificate is limited to a sale between Qualified Distributors .
Signature ___________________________________
Title _____________________________________
FOR USE BY QUALIFIED DISTRIBUTORS ONLY
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