Looking for a Massachusetts Tax Forms And Templates? Download it for free!

Rnv. 5/08

Massachusetts

Revenue

Form ST-5

Sales Tax Exempt

Purchaser Certificate

~~~_!._ __ ~!-~-'!:£!_ t~~-?~¥=-r.

. . .

!.:.'.f~~-r::t-~!l?

. .

r .1..: . .

:'.~2'~~:':!:i~'.~'.Lb2:..:::~~-~.?.'.'.:'..'.''.'.'.'::~''.

. .

: ::..:!o

".!(3i

-~-~::i'.''7:a_1_i~·-~----------·-----·--····

Narn:J

106 Central Street

·······················-·-·--··--- ······················-··-···-···-············-·····---··-····-······-

···--··---··-·-···-··················--···------ ··-·--·····--···--·-----·-··

Welles1ey,

02481

Exemption numbor

042-1

Oale of expirotior. of ccrlificale

·--····--·-----------·----·-----------·--·-·----

QJ/04/19

Ce-rJfication is hereby made that the organization named above is an exempt purchaser under Massactwseus General Laws, Chapter 64H, sec!lons 6(d)

6(e). All

purchases oi tangible persqna! prope1iy or services by this organization are exempt

frorn

taxation under

said

chapter to

the

extent that such

property or services are used in the conduct of the business of the purchaser. Any abuse or misuse of .this certificate by any tax-exempt organization or

any--.unauthorized _use o! this certificate by any individual constitutes

setious violation and

will

lead

revocation .

. :ignatilra

:~*r-- ~

Title

Direct or of Pu

~··-c-h_a_s_i_r_1

g--D-ai_e_ _ _

O_l_/_0_4 _ __ / _0_9 _ __

Warni

Willful mis se 9f this certificate may resuJtin criminal tax ev;ision sanctions of up to one year in prison and $10,000 (S;i0,000 for

.·corporations)

fines.

.~Jame

agenfs

organi~auon

····---·-·---···---··-----··-_ _ W_e

~-~~--~-.!

C_?. . . .

: !}

e g e Pu

~-~~~<!:_S

n g De

!2-1:1-

r t me n.t

Address

106 Central

Street

.-------·----·--"--·-··--··------------··-··-----

. .

---------·---·--·----····--'----·---·-··---·

Ci:y

-·-·-·-·-----

WeUesley

$ta1;;:.l. . K A

Zip

02481

------···---

. A.genfs name

Tina Dolan

···------·····----·----

Address

106 Central Street

z·

Wellesley

Stati.f

'!>02481

eeriiry that in making this purcl1ase, I am acting as an agent for the exempt organization named above (select one):

[] Governri1ent organization (local public school, cityflown government, state agency, etc.).

Attach

Form ST-2,

if available.

Form ST-2

not available, enter exemption number,

lf known:---------·

501(c)(3) organiz

tkm

(parochial school, Scout troop,. etc.). Form

ST·2 mus! be attached.

· Tllfe

bl)te

Buyer

01/04/09

Part 3.

Vendor

information

· :vendor's name

Check applicable .box:

Single purchase certificate (attach detailed receipts

complete Part 4, on 1everse)

. 0

Blanko!

certilicaie

This fo~m is approved.by the .Commis~ioner of Bevenµe and

may

t>e repr<X(uced•.

Form St-5 - Sales Tax Exempt Purchaser Certificate Filing Example - Massachusetts Department Of Revenue Page 2

Related Articles

Related forms

Related Categories