Sstgb Form F0003 - Streamlined Sales And Use Tax Certificate Of Exemption
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1
2Streamlined Sales and Use Tax
Certificate of Exemption
This is a multistate form. Not all states allow all exemptions listed on this form. Purchasers are responsible for
knowing if they qualify to claim exemption from tax in the state that would otherwise be due tax on this sale. The
seller may be required to provide this exemption certificate (or the data elements required on the form) to a state
that would otherwise be due tax on this sale.
The purchaser will be held liable for any tax and interest, and possibly civil and criminal penalties imposed by the
member state, if the purchaser is not eligible to claim this exemption. A seller may not accept a certificate of
exemption for an entity-based exemption on a sale made at a location operated by the seller within the designated
state if the state does not allow such an entity-based exemption.
1.
Check if you are attaching the Multistate Supplemental form.
If not, enter the two-letter postal abbreviation for the state under whose laws you are claiming exemption.
2.
Check if this certificate is for a single purchase and enter the related invoice/purchase order #____
__.
3.
Please Print:________________________________________________________
_________
_____
Name of Purchaser
__________________________________________________________________
_
____
____
Business Address
City
State
Zip Code
Purchaser’s Tax ID Number
State of Issue
Country of Issue
If no Tax ID Number:
1) FEIN
2) Driver’s License Number or
3) Foreign Diplomat Number
State Issued ID Number
Enter one of the
following:
State
No.
Please Print:
Name of seller from whom you are purchasing, leasing or renting
Seller’s address
City
State
Zip code
4.
Type of business. Circle the number that describes your business
01
Accommodation and food services
11
Transportation and warehousing
02
Agricultural, forestry, fishing, hunting
12
Utilities
03
Construction
13
Wholesale trade
04
Finance and insurance
14
Business services
05
Information, publishing and communications
15
Professional services
06
Manufacturing
16
Education and health-care services
07
Mining
17
Nonprofit organization
08
Real estate
18
Government
09
Rental and leasing
19
Not a business
10
Retail trade
20
Other
(explain)__________________________
5.
Reason for exemption. Circle the letter that identifies the reason for the exemption.
A
Federal
government(department)
H
Agricultural production #
B
State or local government
(name)
I
Industrial production/manufacturing #
C
Tribal government
(name)
J
Direct pay permit #
D
Foreign diplomat #
K
Direct mail #
E
Charitable organization #
L
Other
(explain)
F
Religious or educational organization
G
Resale
6.
Sign here. I declare that the information on this certificate is correct and complete to the best of my knowledge and belief.
______________________________________________________________________________________________
Signature of Authorized Purchaser
Print Name
Title
Date
SSTGB Form F0003
Exemption Certificate
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