Form R-1041 - Sales/use Exemption Certificate Page 2

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GENERAL INFORMATION
This form is for the completion and presentation to their vendors by medical institutions and retail dealers in lieu of payment
of the state sales tax when making purchases of tangible personal property that the institutions or retail dealers will sell to
patients or customers without the collection of the state sales tax, by application of one or more of the statutory exemptions
listed above. Vendors will retain the form and attached tangible personal property list as documentation of the exemptions
allowed to their customers.
This form cannot be used by medical institutions when making purchases of durable assets for institutional use, such as
laboratory equipment, X-ray film, bedding, or wheelchairs for general patient use.

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