Form Dr-97 - Suggested Format For An Exemption Certificate Based On Property'S Use


Suggested Format for an Exemption
R. 12/17
Certificate Based on Property’s Use
This is to certify that the tangible personal property purchased, leased, licensed, or rented; or services purchased on
or after_______________(date) from _________________________________________(selling dealer’s business name) is
purchased, leased, licensed, or rented for the following purpose as checked in the space provided below.
Note: This is not intended to be an exhaustive list.
Materials, containers, labels, sacks, bags, or similar
Educational materials, such as glue, paper, paints,
items intended to accompany a product for sale at
crayons, unique craft items, scissors, books, and
other than retail, as provided in section (s.)
educational toys, purchased by child care facilities
212.02(14)(c), Florida Statutes (F.S.), by persons who
outlined in s. 402.305, F.S., that hold a current license
are not required to be registered under
under s. 402.308, F.S., hold a current Gold Seal
s. 212.18(3), F.S.
Quality Care designation as provided in s. 402.281,
F.S., and provide all employees with basic health
Incorporation into items of tangible personal property
insurance as defined in s. 627.6699(12), F.S., as
manufactured, produced, compounded, processed,
provided in s. 212.08(5)(m), F.S.
or fabricated for one’s own use, as provided in Rule
12A-1.043, Florida Administrative Code (F.A.C.).
Motor vehicle rented or leased by a dealer who will
provide the motor vehicle at no charge to a person
Printing of a publication exempt under the provisions
whose motor vehicle is being repaired, adjusted, or
of s. 212.08(7)(w), F.S.
serviced by the dealer, as provided in
Items, such as paper and ink, that will be
s. 212.0601(4), F.S.
incorporated into and become a component part of a
publication exempt under the provisions of
s. 212.08(7)(w), F.S.
Other (include description and statutory citation):
Note: There are other suggested formats for exemption certificates based on the use of the property or services that
are provided in other sections of Rule Chapter 12A-1, F.A.C., and in Tax Information Publications (TIPs) issued by the
I understand that if I use the property or service for any nonexempt purpose, I must pay tax on the purchase or
lease price of the taxable property or service directly to the Department of Revenue.
I understand that if I fraudulently issue this certificate to evade the payment of sales tax, I will be liable for
payment of the sales tax plus a penalty of 200 percent of the tax and may be subject to conviction of a third
degree felony.
The exemption specified by the purchaser may be verified by calling 850-488-6800.
Purchaser’s name: ______________________________________________________________________________________
Purchaser’s address: _____________________________________________________________________________________
Name and title of purchaser’s authorized representative: ______________________________________________________
By: _____________________________________________________________________________________________________
(Signature of purchaser or authorized representative)
Title: _______________________________________________________________ Date: _____________________________
(Title – only if purchased by an authorized representative of a business entity)
Reference: Rule 12A-1.038, F.A.C.


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Parent category: Financial