Form R-1045 - Sales Tax Exemption Certifi Cate For Purchases Of Mobile Homes By Enrolled Tribal Members For Use On Federally Recognized Indian Reservation Supremacy Clause Of The U.s. Constitution

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R-1045 (9/07)
Sales Tax Exemption Certifi cate for Purchases of
Mobile Homes by Enrolled Tribal Members for Use on
Federally Recognized Indian Reservation
Supremacy Clause of the U.S. Constitution
Description of Mobile Home
Type
Make
Model
Year
Serial No.
Dimensions
This certifi es that the mobile home described above was purchased for use on a federally recognized Indian Reservation and that the
purchaser is an enrolled member of the Federally Recognized Tribe.
The purchaser certifi es the following:
The purchaser is an Enrolled Tribal Member;
The mobile home was purchased by and will be titled in the Enrolled Tribal Member’s name; and
The mobile home will be delivered and immobilized for permanent use on the Federally Recognized Indian Reservation lands.
Signature
X
Enrolled Tribal Member Name
Federally Recognized Indian Tribe Name
Address
Telephone Number
City
State
ZIP
Certifi cation of Purchaser’s Status as an Enrolled Tribal Member
Signature of Tribal Chairman
Date
X
Tribal Chairman Name
Federally Recognized Indian Reservation Name
By signing this document, the Tribal Chairman certifi es that the purchaser is an Enrolled Tribal Member who resides on the Federally
Recognized Indian Reservation as indicated by the purchaser.

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