Form Agq-100 - Agricultural Equipment Exemption Usage Questionnaire
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1
2Agricultural Equipment Exemption Usage
Questionnaire
Form AGQ-100
State Form 52108 (R2/8-07)
Your FID#
or
(Federal Identifi cation Number)
SS#
:
(Social Security Number)
Name of Purchaser:
Address:
City
State
Zip
(1) Describe your equipment purchase.
(2) Are you occupationally engaged in agriculture for a living?
Yes
No
(Check one)
(3) What is the horsepower rating for this equipment?
(4) For the section below, list the best estimate of daily use over a year’s time period that this equipment is utilized for various
activities. If the listed activities do not describe your usage please write-in your usage on Lines M through O. You may attach
additional pages, if needed.
The equipment purchase described in (1) above is
The number of days used during
used to perform the following activities listed below.
the year for each activity noted.
Check all that apply.
a) seeding of crops to be sold
(list type of crop)
b) fertilization of crops to be sold
c) tilling of land for crops to be sold
d) harvesting of crops to be sold
e) hauling of animal waste
f) hauling feed to livestock to be sold
g) hauling tools & equipment
h) transporting employees
i) checking on livestock
j) trash removal
k) running/checking fence around property lines
l) recreational riding
m) other use -
n) other use -
o) other use -
Information furnished above is subject to audit verifi cation.
I certify, under penalty of perjury, the information contained in this questionnaire is true, correct and complete to the best of my
knowledge and belief.
Purchaser’s Signature:
Title:
Date:
Mail to:
Indiana Department of Revenue
“This agency is requesting the disclosure of your Social Security number
Enforcement Division/Audit
in accordance with IC 4-1-8-1. Disclosure is mandatory; this record can-
100 N. Senate Ave., IGCN-241
not be processed without it.”
Indianapolis, IN 46204-2233
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