Uniform Sales & Use Tax Certificate 3/4 Multijurisdiction

Revised 04/12/99, Page 1 of 4

UNIFORM SALES & USE TAX CERTIFICATE  MULTIJURISDICTION

The below-listed states have indicated that this form of certificate is acceptable, subject to the notes on pages 2 - 4. The issuer and the

recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change

from time to time.

Issued to Seller: ______________________________________________________________________________________________

Address:

_______________________________________________________________________________________________

I certify that:

is engaged as a registered

Name of Firm (Buyer): ______________________________________________________ Wholesaler

_________________

Retailer

_________________

Address

______________________________________________________ Manufacturer

_________________

Seller (California)

_________________

______________________________________________________ Lessor (see notes

on pages 2 - 4)

_________________

______________________________________________________ Other (Specify)

_________________

and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases

are for wholesale, resale, ingredients or components of a new product or service 1 to be resold, leased, or rented in the normal course of

business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:

Description of Business: ________________________________________________________________________________________

General description of tangible property or taxable services to be purchased from the seller: __________________________________

___________________________________________________________________________________________________________

State

State Registration, Seller's

State

State Registration, Seller's

Permit, or ID Number

of Purchaser

_____________________________

1,15

_____________________________

1,7

_____________________________

1,8

_____________________________

I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use

Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing.

This certificate shall be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until

canceled by us in writing or revoked by the city or state.

Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.

Authorized Signature:

_____________________________________________________

(Owner, Partner or Corporate Officer)

Title:

_____________________________________________________

Date:

_____________________________________________________

Uniform Sales & Use Tax Certificate 3/4 Multijurisdiction - 1999

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