Form R-1041 - Sales/use Exemption Certificate

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R-1041 (8/16)
Institutional or Retail Dealer Purchases of
Louisiana Department of Revenue
Medical-Related Property
Revenue Processing Center
P.O. Box 4998
Sales/Use Exemption Certificate
Baton Rouge, LA 70821-4998
La. R.S. 47:305(D)(1) et.al., 47:305.2, and 47:315.3
Phone: (855) 307-3893
PLEASE PRINT OR TYPE.
Vendor’s Information
Vendor Name
Address
City
State
ZIP
This certifies that the tangible personal property on the attached list purchased from the above referenced vendor will be sold or dispensed
to and fully consumed by the institution’s patients or the retail customers as:
Mark one or more, as applicable:
Tax Rate
Tax Rate
Tax Rate
Sales Return
Description
4/1/2016-
7/1/2016-
7/1/2018-
Code
6/30/2016
6/30/2018
3/31/2019
Schedule A,
Drugs prescribed by physicians or dentists. (R.S. 47:305(D)(1)(j))
0%
0%
0%
Line 25
Orthotic, including prescription eyeglasses and contact lenses, and prosthetic devices
5023
and wheelchairs and wheelchair lifts prescribed by physicians, optometrists or licensed
5%
0%
0%
chiropractors for personal consumption or use. (R.S. 47:305(D)(1)(k))
Ostomy, ileostomy, or colostomy devices or appliances, including catheters or any related
5024
items, which are required as the result of any surgical procedure by which an artificial open-
5%
0%
0%
ing is created in the human body for the elimination of natural waste. (R.S. 47:305(D)(1)(l))
5025
Patient aids prescribed by physicians or licensed chiropractors for home use. (R.S. 47:305(D)(1)(m)
5%
3%
0%
Medical devices to be used personally and exclusively by the patients or retail customers
5027
in the medical treatment of various diseases under the supervision of and prescribed by
5%
3%
0%
registered physicians. (R.S. 47:305(D)(1)(s))
Orthodox devices, prosthetic devices, prostheses, and restorative materials utilized
5028
or prescribed by dentists in connection with health care treatment or for personal
5%
3%
0%
consumption or use. (R.S. 47:305(D)(1)(t))
5036
Sales of nonprescription insulin, for personal consumption or use. (R.S. 47:305.2)
5%
3%
0%
Tangible personal property provided to a patient in a sale, lease or rental transaction, and
7015
0%
0%
0%
for which the provider is entitled to payment by or under Medicare. (R.S. 47:315.3)
Notice to Seller: Report these sales on the appropriate sales tax return schedule using the above referenced sales tax
exemption codes if applicable.
Buyer’s Information
Buyer
Buyer’s Address
City
State
ZIP
Authorization
Authorized Representative
Title
Signature
Date
(mm/dd/yyyy)
Questions about the completion of this form should be sent to
Sales.Inquiries@la.gov.

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