Form Dr 0563 - Sales Tax Exemption Certificate Multi-Jurisdiction
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2DR 0563 (01/05/04)
COLORADO DEPARTMENT OF REVENUE
SALES TAX EXEMPTION CERTIFICATE
1375 SHERMAN STREET
DENVER COLORADO 80261
MULTI - JURISDICTION
See reverse side for instructions.
Issued to (Seller)
Address
Name of Firm (Buyer)
I
Street Address or Post Office Box Number
CERTIFY
THAT
City
State
ZIP Code
WHOLESALER
RETAILER
MANUFACTURER
LESSOR*(See note on reverse side)
CHARITABLE OR RELIGIOUS
POLITICAL SUBDIVISION OR GOVERNMENTAL AGENCY
OTHER (Specify) _______________________________________________________________________
QUALIFIES
1) and is registered with the below listed states and cities within which your firm would deliver purchases to us which are for resale or lease by us in the
AS
(Check each
applicable
normal course of our business which is _________________________________________________________________________________ or
item)
2) that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
CHARITABLE OR RELIGIOUS
POLITICAL SUBDIVISION OR GOVERNMENTAL AGENCY
OTHERWISE EXEMPT BY STATUTE (SPECIFY) ____________________________________________
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
City or State
State Registration or ID Number
If the list of states and cities is more than six (6), attach a list to this certificate.
I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due direct
to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be part of each order which we may hereafter
give to you, unless otherwise specified, and shall be valid until cancelled by us in writing or revoked by the city or state.
General description of products to be purchased from the seller
Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.
Authorized Signature (Owner, Partner or Corporate Officer)
Title
Date
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Parent category: Financial