Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax

Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax - 2014 Page 4

Page 4 of 4 ST-140 (2014)

I certify that the above statements are true and correct, and I make these statements with the knowledge that willfully issuing a false or fraudulent

document with the intent to evade tax may constitute a felony under New York State Tax Law, punishable by a substantial fine and a possible jail

sentence. I also understand that the Tax Department is authorized to investigate the validity or the accuracy of any information entered on this

document.

Purchaser’s signature

Date

Telephone number for purchaser

(

)

Printed name of preparer

Preparer’s PTIN

(if other than purchaser)

Preparer’s address

Preparer’s NYTPRIN

Excl. code

Preparer’s signature

Preparer’s telephone number

(if other than purchaser)

(

)

Mail this return and remittance to:

NYS TAX DEPARTMENT

TDAB — CASUAL SALES UNIT

W A HARRIMAN CAMPUS

ALBANY NY 12227-0931

Private delivery services

To use a private delivery service, see Publication 55, Designated Private Delivery Services.

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Sales Tax Information Center:

(518) 485-2889

To order forms and publications:

(518) 457-5431

Text Telephone (TTY) Hotline

(for persons with hearing and

speech disabilities using a TTY):

(518) 485-5082

44000400140094

Form St-140 - Individual Purchaser'S Annual Report Of Sales And Use Tax - 2014 Page 4