Out-Of-State Purchase Exemption Certificate

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Check Applicable Block
OUT–OF–STATE PURCHASE
Important—Not valid
Blanket
EXEMPTION CERTIFICATE
unless completed.
Single Purchase
I hereby certify that _______________________________________________________________________________
Name of Agency or Institution
__________________________________________________________________________________________________
Address
is an out–of–state agency, organization or institution exempt in its state of residence from sales and use tax and that the tangible
personal property, digital property, or services to be purchased from:
__________________________________________________________________________________________________
Name of Vendor
__________________________________________________________________________________________________
will be used solely for the exempt purpose.
Address
Description of property or services to be purchased: _____________________________________________________
__________________________________________________________________________________________________
In the event that the property or services purchased are not used for the exempt purpose, it is understood that I am required
to pay the tax measured by the purchase price.
It is also understood that the information contained herein can be provided to the state of residence. Under penalties of
perjury, I swear or affi rm that the information on this certifi cate is true and correct as to every material matter.
___________________________________________________
__________________________________________
Authorized Signature
Title
___________________________________________________
__________________________________________
Exemption or ID Number
Date
CAUTION TO SELLER: This certifi cate can be used only for sales to agencies, organizations or
institutions which, as an entity, are exempt from sales and use taxes in their state of residence. It cannot
51A127 (12-09)
be used to claim exemption for specifi c types of property which may be exempt in the purchaser’s state
DEPARTMENT OF REVENUE
of residence. Sellers may not accept this certifi cate in lieu of a Resale Certifi cate, Multijurisdictional
Frankfort, Kentucky 40620
Certifi cate or Direct Pay Authorization.

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