SALES AND USE TAX EXEMPTION CERTIFICATION
(01-339 Back) (PDF Version)
|Name of purchaser, firm or agency||Phone (Area code and number)|
|Address (Street & number, P.O. Box or Route number)|
|City, State, ZIP code|
the purchaser named above, claim an exemption from payment of sales and use
taxes for the purchase of taxable items described below or on the attached order
or invoice form:
|City, State, ZIP code:|
|Description of items to be purchased or on the attached order or invoice:|
|Purchaser claims this exemption for the following reason:|
I understand that it is a criminal offense to give an exemption certificate to the seller for taxable items that I know, at the time of purchase, will be used in a manner other than that expressed in this certificate and, depending on the amount of tax evaded, the offense may range from a Class C misdemeanor to a felony of the second degree.
This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts.