Excise Tax Exemption Certificate

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EXCISE TAX EXEMPTION CERTIFICATE
(Date) ______________/_____________, 20_____.
I hereby certify that I am ______________________________ of ______________________________________;
(Title of Officer)
(State or Local Government)
That I am authorized to execute this certificate; and that the article or articles specified in the Accompanying
order (or) All orders placed by the purchaser for the period commencing
_____/_____/_____ And ending ______/_____/______ (period not to exceed 12 Calendar quarters) are,
(Date)
(Date)
Or will be, purchased from Botach Tactical 3423 West 43rd Place, Los Angeles, CA 90008 For the exclusive
use of the
_____________________________________________, Of _________________________________________.
(Governmental Unit)
(State or Local Government)
I understand that the exemption from tax in the case of sales of articles under this exemption certificate to a
State, etc., is limited to the sale of articles purchased for its exclusive use. I understand that fraudulent use of
this certificate for the purpose of securing this exemption will subject me and all parties making such fraudulent
use of this certificate to all applicable criminal penalties under the Internal Revenue Code.
Signature:
______________________________________________________________________
Address:
_______________________________________________________________________
City:
__________________________ State: ______________ Zip: __________
Phone:
________ / _______ - __________
Fax: ________ / _______ - ________
A sale of an article to a State or local government for resale is not considered to be a sale for the “exclusive use”
of State or local government, within the meaning of section 4221 (a) (4) of the code, and, therefore, such sales
may not be made tax-free. Such sales may not be made tax-free even if the reseals are made to government
employees, or the article is an item of equipment the employee is required to possess in carrying out his/her
duties.
Please mail original To:
BOTACH TACTICAL 3423 West 43
rd
Place, Los Angeles, CA 90008
PH: 323/294-5555 Fax:323/294-3542

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