Form St-119.1 - Exempt Organization Exempt Purchase Certificate

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New York State Department of Taxation and Finance
New York State and Local Sales and Use Tax
Exempt Organization
Exempt Purchase Certificate
Your exempt organization number is
not your federal employer identification number.
Exempt organization number (6-digit number
Single purchase certificate
issued by the New York State Tax Department)
Blanket certificate
EX -
Name of seller
Name of buyer
Static Control Component,s Inc.
Street address
Street address
3010 Lee Avenue
State ZIP code
State ZIP code
The exempt organization must be the direct purchaser and payer of record.
You may not use this form to purchase motor fuel or diesel motor fuel exempt from tax.
Representatives of governmental agencies or diplomatic missions may not use this form.
I certify that the organization named above holds a valid Form ST-119, Exempt Organization
Certificate, and is exempt from New York State and local sales and use taxes on its purchases.
I also certify that the above statements are true and correct. I make these statements with the
knowledge that knowingly making a false or fraudulent statement on this document is a
misdemeanor under section 1817 of the New York State Tax Law and section 210.45 of the
Penal Law, punishable by imprisonment for up to a year and a fine of up to $10,000 for an
individual or $20,000 for a corporation. I understand that the Tax Department is authorized to
investigate the validity of the exemption claimed or the accuracy of any information entered on
this form.
Print or type name of officer of organization
Signature of officer of organization
Date issued
Do not write in this box


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Parent category: Financial