Standard Municipal Home Rule Affidavit Of Exempt Sale Form
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2Standard Municipal Home Rule Affidavit of Exempt Sale
This form is required by home rule municipalities within the State of Colorado for any
transaction on which an exemption from tax is claimed. The seller is required to maintain a
completed form for each tax-exempt sale.
Furnish this form to the seller. Do not return this form to the taxing jurisdiction.
☐
☐
(QUALIFICATIONS MAY VARY BY JURISDICTION – SEE INSTRUCTIONS)
PURCHASE FOR RESALE - OR -
PURCHASE FOR WHOLESALE
STATE LICENSE NUMBER (NOT FEIN NUMBER): _____________________________
EXPIRATION _______________
LOCAL LICENSE NUMBER (IF APPLICABLE): ________________________
ISSUING MUNICIPALITY: _____________________
☐ I AFFIRM ITEMS PURCHASED ARE FOR RESALE/WHOLESALE IN THE ORDINARY COURSE OF BUSINESS. INITIAL _____________
☐
PURCHASE FOR RELIGIOUS OR CHARITABLE ORGANIZATION
(EXEMPTIONS MAY VARY BY JURISDICTION)
STATE TAX EXEMPT NUMBER (NOT FEIN NUMBER): _________________________
LOCAL TAX EXEMPT NUMBER (IF APPLICABLE): ________________________
ISSUING MUNICIPALITY: _____________________
PAYMENT INFORMATION (REQUIRED TO MEET ONE OF THE FOLLOWING):
☐ PAID BY CASH AND ACCOMPANIED BY A PURCHASE ORDER FROM THE ORGANIZATION
☐ PAID BY CHECK DRAWN ON FUNDS OF THE EXEMPT ORGANIZATION
☐ PAID BY PURCHASING CARD BEARING INFORMATION OF THE EXEMPT ORGANIZATION
THE EMBOSSED NAME OF THE CARD IS:________________________________________
☐ PAID BY COMMERCIAL CARD NOT A PERSONAL CREDIT CARD - CARD’S LAST FOUR DIGITS: __________
☐
PURCHASE FOR FEDERAL, STATE, OR LOCAL GOVERNMENT
CREDIT CARD NUMBER (FIRST SIX AND LAST FOUR ONLY:________-_______XX-XXXX-_________.
FEDERAL GOVERNMENT (PAYMENT INFORMATION - REQUIRED TO MEET ONE OF THE FOLLOWING):
☐ GSA SMARTPAY2 CARD – FLEET CARD WITH PICTURE OF A ROAD AND FLAG
☐ GSA SMARTPAY2 CARD – PURCHASE CARD WITH PICTURE OF A KEYBOARD AND FLAG
☐ GSA SMARTPAY2 CARD – TRAVEL CARD WITH PICTURE OF AN AIRPLANE AND FLAG
☐ GSA SMARTPAY2 CARD – INTEGRATED CARD WITH PICTURE OF AN EAGLE AND FLAG
☐ DEPT OF INTERIOR AGENCY ISSUED CARD – AGENCY NAME _______________________________________.
STATE AND LOCAL GOVERNMENT (PAYMENT INFORMATION - REQUIRED TO MEET ONE OF THE FOLLOWING):
☐ PAID BY CASH AND ACCOMPANIED BY PURCHASE ORDER ISSUED BY THE GOVERNMENT AGENCY
☐ PAID BY CHECK ISSUED BY AND DRAWN ON FUNDS FROM THE GOVERNMENT AGENCY
☐ PAID BY GOVERNMENT PURCHASE CARD AS DESIGNATED ON THE CARD
STATE TAX EXEMPT NUMBER PRINTED ON THE CARD (COLORADO ONLY): _____________________.
☐ CHECK IF THE CARD STATES “FOR OFFICIAL STATE USE ONLY” OR “TAX EXEMPT”
☐
PURCHASE FOR FOREIGN AND DIPLOMATIC EXEMPTIONS (REQUIRED TO MEET THE FOLLOWING):
☐ PURCHASER PRESENTS A STATE DEPARTMENT ISSUED CARD WITH THE NAME/PHOTO OF THE BEARER ON THE CARD.
IF PRESENTED WITH THIS CARD, DOCUMENTATION OF FORM OF PAYMENT IS NOT REQUIRED (EXCLUDING MISSION CARD).
☐
OTHER QUALIFIED EXEMPTION
NATURE OF EXEMPTION: __________________________________________________
EXEMPT NUMBER: _____________________
LEGAL NAME OF COMPANY/ORGANIZATION/AGENCY NAME
PURCHASER NAME (PRINTED)
ADDRESS
CITY
STATE
ZIP + 4
PHONE
STATE / DRIVERS LICENSE #
DESCRIPTION OF NORMAL COURSE OF BUSINESS
Under penalty of perjury, I swear or affirm that the information on this form is true and correct as to every material matter. I affirm that the
items purchased tax-exempt will be used for official business of the above-named organization or agency. I accept that I remain directly
liable for the taxes and any applicable penalty or interest if my purchase is found to not qualify for the exemption or if the information
asserted in this form is deemed fraudulent.
SIGNATURE
DATE
SELLER NAME
LOCATION #
DATE
TRANSACTION ID
EMPLOYEE ID# / INITIALS
DESCRIPTION OF ITEMS PURCHASED OR ATTACH DUPLICATE RECEIPT/INVOICE
EXEMPTED AMOUNT OF PURCHASE
Page 1 of 2
Revised 5/1/2014
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