Form R-1355 - Exemption Certificate
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1R-1355 (7/14)
_____________________
Exemption Certificate
Covering purchases of tangible personal property for
resale by a blind person in the conduct of a business
as provided by Revised Statutes 47:305.15
_____________________
This certifies that the undersigned is a “person who is blind”, as provided in La. R.S.
23:3021(B), meaning the undersigned is a person who, after examination by a licensed
physician skilled in diseases of the eye or by a licensed optometrist, has been determined to
have not more than 20/200 central visual acuity in the better eye with correcting lenses, or
an equally disabling loss of the visual field as evidenced by a limitation to the field of vision
in the better eye to such a degree that its widest diameter subtends an angle of no greater
than twenty degrees.
Signature of Licensed Physician/Licensed Optometrist
The blind person certifies the following:
• The purchases are made in the conduct of a business which is exempt from license taxes
by R.S. 23:3032 through 3033.
• The business is conducted by the blind person exclusively for his own support or for the
support of his family;
• The value of the business’s stock of goods on hand, or equipment or capital stock never
exceeds $2,000;
• The business does not operate as a place of amusement.
The undersigned purchaser further agrees that should the sale later be held subject to the
sales tax, the purchaser assumes full liability for payment of the tax, penalty, and interest.
PLEASE PRINT OR TYPE.
Signature of Blind Person
Date (mm/dd/yyyy)
Qualifying Blind Person
Address
City
State
ZIP
Any purchaser who fraudulently signs this certificate without intent to use the property
as above stated shall be subject to all penalties provided by Title 47 of the Louisiana
Revised Statutes.
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