Form St-136a - Indiana Out-Of-State Purchasers Sales Tax Exemption Affidavit

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Indiana Department of Revenue
ST-136A
Single Purchase
SF 48095 (10-96)
Blanket Exemption
Indiana Out-of-State Purchasers Sales Tax
Rev. 8-96
(Should Be Renewed Annually)
Exemption Affidavit
Name of Purchaser
Resident State Exemption Number
Address
City
State
Zip Code
Purchaser's Business Type (Must check one):
Manufacturing, Production
Government Agency
Retailer or Wholesaler
Not-for-Profit Agency
Agriculture
Public School Corporation
Description of Property Purchased _______________________________________________________________
____________________________________________________________________________________________
I hereby certify under penalty of perjury that the property described above is purchased exempt from Indiana sales
tax for the following reasons: ____________________________________________________________________
_______________________________________________________________________________________________
_____________________________________________________________________________________________
I further certify that such property will be removed immediately to the State of _____________________ and this
property will not be stored, used or consumed in Indiana.
I further certify that the purchase of the above described property would be exempted if purchased in the state of
exempt registration.
_____________________________________________
_______________________________
________________________
Purchaser's Signature
Title
Date
Must Be Completed By Seller
Total Sales Price $ __________________ (If blanket, estimate annual liability.)
Name of Seller
T.I.D.#
Address
City
State
Zip Code
To be valid the price information must be provided on this form. The original copy should be retained by seller
for audit purposes. If more than one purchase is to be covered by this certificate, indicate the type of property
in the description blank.

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