Streamlined Sales and Use Tax Agreement Certificate of Exemption
This is a multi-state form. Not all states allow all exemptions listed on this form. Purchasers are responsible for knowing if they qualify to
claim exemption from tax in the state that would otherwise be due tax on this sale. The seller may be required to provide this exemption
certificate (or the data elements required on the form) to a state that would otherwise be due tax on this sale.
The purchaser will be held liable for any tax and interest, and possibly civil and criminal penalties imposed by the member state, if the
purchaser is not eligible to claim this exemption. A seller may not accept a certificate of exemption for an entity-based exemption on a sale
made at a location operated by the seller within the designated state if the state does not allow such an entity-based exemption.
1. Check if you are attaching the Multi-state Supplemental form.
If not, enter the two-letter postal abbreviation for the state under whose laws you are claiming exemption.
2. Check if this certificate is for a single purchase and enter the related invoice/purchase order #________________________________.
3. Please print___________________________________________________________________________________________
Name of purchaser
__________________________________________________________________________________________________________________
Business Address City State Zip Code
Purchaser’s Tax ID Number State of Issue Country of Issue
__________________________________________________________________________________________________________________
If no Tax ID Number | FEIN | Driver’s License Number/State Issued ID Number | Foreign diplomat number
Enter one of the following: | | |
______________________|__________________ |_State of Issue: Number
____________________________|_____________________
Name of seller from whom you are purchasing, leasing or renting
_________________________________________________________________________________________
Seller’s address City State Zip code
_________________________________________________________________________________________
4. Type of business. Circle the number that describes your business
Accommodation and food services
Transportation and warehousing
Agricultural, forestry, fishing, hunting
Information, publishing and communications
Education and health-care services
Other (explain)__________________________
5. Reason for exemption. Circle the letter that identifies the reason for the exemption.
Federal government (department)_________________
Agricultural production #_____________________
State or local government (name)_________________
Industrial production/manufacturing #___________
Tribal government (name)_______________________
Direct pay permit #__________________________
Foreign diplomat # ____________________________
Direct mail #_______________________________
Charitable organization #________________________
Other (explain)______________________________
Religious or educational organization #_____________
Resale #_____________________________________
6. Sign here. I declare that the information on this certificate is correct and complete to the best of my knowledge and belief.
Signature of Authorized Purchaser Print Name Here Title Date
__________________________________________________________________________________________________________________
SSTGB Form F0003 Exemption Certificate (5/10/11)
