Form R-1049 - Notarized Statement Of Exclusion

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R-1049 (12/05)
Notarized Statement of Exclusion
For the purchase, lease, rental, or repair of tangible personal property used for the repair of manufacturing
machinery and equipment that was destroyed, lost, or damaged by Hurricane Katrina or Hurricane Rita
Legal Name:______________________________________________________________________________
Trade Name:
____________________________________________________________________________
Address: ________________________________________________________________________________
City
State
ZIP
City, State, and Zip Code: __________________________________________________________________
Louisiana Sales Tax Account Number: ________________________________________________________
Under the authority of Act 47 of the 2005 First Extraordinary Session, a taxpayer that has been certified as a
“manufacturer” by the Department of Revenue in accordance with R.S. 47:301(3)(i)(iii) may purchase machin-
ery and equipment, parts, or services or lease or rent tangible personal property fully exempt from state sales
tax when the purchase is for the replacement or repair of manufacturing machinery and equipment that has
been lost or damaged by wind, water, fire, or criminal act as a result of the conditions created by Hurricanes
Katrina and Rita. A copy of the Manufacturer’s Exemption Certificate must be on file with to the vendor before
accepting this notarized statement to exempt the transaction.
Under penalty of perjury, I/we certify that the taxpayer listed above is:
• A manufacturer, as defined by R.S. 47:301(3)(i)(ii), that has been certified by the Louisiana Department of
Revenue; and
• The machinery and equipment, parts, or services are purchased, leased, or rented to replace or repair man-
ufacturing machinery and equipment lost or damaged by wind, water, fire, or criminal act as a result of con-
ditions created by Hurricane Katrina or Hurricane Rita.
__________________________________________________________
__________________________
Signature of Taxpayer or Taxpayer’s Representative and Title
Date
SWORN TO AND SUBSCRIBED BEFORE ME THIS __________ day of _____________________________
Notary ____________________________________________________
Notary Number
____________________________________________
Under the authority of Act 47 of the 2005 First Extraordinary Session, the entity listed above shall be entitled to
purchase, use, lease, or rent machinery and equipment, repair parts or repair services without the payment of
Louisiana state sales or use tax provided that the purchases are for the repair or replacement of manufacturing
machinery and equipment that was damaged or destroyed during Hurricanes Katrina or Rita.
__________________________________________________________
________________________
Signature of Officer of Department of Revenue and Title
Date
*This exemption expires on July 1, 2007.

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