Fillable Form 1: Certicate of Exemption

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Form 1: Certicate of Exemption

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The Form 1: Certicate of Exemption form is 2 pages long and contains:

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  • 32 check-boxes
  • 71 other fields

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Check if this certicate is for a single purchase and enter the related invoice/purchase order # .
Streamlined Sales and Use Tax Agreement
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 certicate (or 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 certicate 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.
Certicate of Exemption
01 Accommodation and food services
02 Agricultural, forestry, shing, and hunting
03 Construction
04 Finance and insurance
05 Information, publishing, and communications
06 Manufacturing
07 Mining
08 Real estate
09 Rental and leasing
10 Retail trade
11 Transportation and warehousing
12 Utilities
13 Wholesale trade
14 Business services
15 Professional services
16 Education and health-care services
17 Nonprot organization
18 Government
19 Not a business
20 Other (explain)
If not, enter the two-letter postal abbreviation for the state under whose laws you are claiming exemption.
Type of business. Check the number that describes your business.
Signature of authorized purchaser Print name here Title Date
Sign here. I declare that the information on this certicate is correct and complete to the best of my knowledge and belief.
Reason for exemption. Check the letter that identies the reason for the exemption.
Seller’s address City State Zip code
Name of purchaser
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
Business address
City State Zip code
Purchaser’s tax ID number State of issue Country of issue
Name of seller from whom you are purchasing, leasing, or renting
H Agricultural production #
I Industrial production/manufacturing #
J Direct pay permit #
K Direct mail #
L Other
(explain)
A Federal government (department)
B State or local government (name)
C Tribal government (name)
D Foreign diplomat #
E Charitable organization #
F Religious or educational organization #
G Resale #
Web-Fill
12-09
E-595E
Please print
Check if you are attaching the Multistate Supplemental form.
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CLEAR
Streamlined Sales and Use Tax Agreement
Certicate of Exemption: Multistate Supplemental
Name of purchaser
State Reason for exemption Identication number (if required)
AR*
IA
IN
KS
KY
MI
MN
NC
ND
NE
NJ
NV
OH
RI
OK
SD
TN*
UT
VT
WV
WY
*SSUTA Direct Mail provision is not in effect for Arkansas and Tennessee.
Page 2
E-595E
Web-Fill
12-09
Use this form to claim exemption from sales tax on purchases of otherwise taxable items. The purchaser must
complete all elds on the exemption certicate and provide the fully completed certicate to the seller in order to
claim exemption.
Warning to purchaser: You are responsible for ensuring that you are eligible for the exemption you are claiming.
You will be held liable for any tax and interest, and possibly penalties imposed by the member state due the tax
on your purchase, if the purchase is not legally exempt.
Purchaser instructions for completing the exemption certicate
1. Some purchasers may wish to complete a single certicate for multiple states where they conduct business
and, regularly, make exempt purchases from the same seller. If you do, check the box on the front of the
SSUTA Certicate of Exemption to indicate that you are attaching the Multistate Supplemental form on page 2.
CAUTION: Certicates completed with a multistate supplement may include non-member states of the SST
Governing Board, provided those states have agreed to accept the SSUTA Certicate of Exemption. Both
sellers and purchasers MUST BE AWARE that these additional non-member states may not have adopted
the SSUTA provisions for Direct Mail. Additionally, completion of this certicate in its entirety may not fully
relieve the seller from liability unless non-member states’ requirements have been met.
If
you are not attaching the Multistate Supplemental form, enter the two-letter postal abbreviation “NC” in
the boxes provided if you are claiming an exemption from sales and use tax imposed by the State of North
Carolina. If you are claiming an exemption from more than one member state, complete the SSUTA Certicate
of Exemption: Multistate Supplemental form.
2.
Single purchase exemption certicate: Check this box if this exemption certicate is being used for a
single purchase. Include the invoice or purchase order number for the transaction.
If
this boxed is not checked, this certicate will be treated as a blanket certicate. A blanket certicate
continues in force so long as the purchaser is making recurring purchases (at least one purchase within a
period of twelve consecutive months) or until otherwise cancelled by the purchaser.
3.
Purchaser information: Complete the purchaser and seller information section, as requested. An
identication number for you or your business must be included. Include your North Carolina sales and
use tax account ID number or North Carolina sales and use tax exemption number, as appropriate. If a
transaction does not require the use of a registration or exemption number, enter the Federal Employer
Identication Number (FEIN) issued to your business, or if no FEIN is required, enter your personal driver’s
license number and the state that it is issued by. Foreign diplomats and consular personnel must enter the
individual tax identication number shown on the sales tax exemption card issued to you by the United States
Department of State’s Ofce of Foreign Missions.
Multistate Purchasers: The purchaser should enter its headquarters address as its business address.
4.
Type of business: Circle the number that best describes your business or organization. If none of the
categories apply, circle number 20 and provide a brief description.
5.
Reason for exemption: Circle the exemption that applies to your business and enter the additional information
requested for that exemption. If the member state that is due tax on your purchase does not require the
additional information requested for the exemption reason code circled, enter “NA” for not applicable on
the appropriate line. If an exemption that is not listed applies, circle “L Other” and enter an explanation.
The explanation for “L Other” must include a clear and concise explanation of the reason for the exemption
claimed.
Certicate of Exemption Instructions
Streamlined Sales and Use Tax Agreement
Certicate of Exemption Instructions - Continued
Streamlined Sales and Use Tax Agreement
Multistate Purchasers: Attach the SSUTA Certicate of Exemption: Multistate Supplemental form and
indicate the applicable reason for exemption and identication number (if required) for each of the additional
states in which the purchaser wishes to claim exemption from tax.
CAUTION: The exemptions listed are general exemptions most commonly allowed by member states. However,
each state’s laws governing exemptions are different. Not all of the reasons listed may be valid exemptions
in the state in which you are claiming exemption. In addition, each state has other exemptions that are not
listed on this form. To determine what sales and use tax exemptions are allowed in a particular state refer to
the state’s web site or other information available relating to their exemptions.
For
information on exemption certicate procedures and exemption number requirements in North Carolina,
see Section 52 of the Sales and Use Tax Technical Bulletins which can be found on the Department’s website
at www.dornc.com, or you may contact the Taxpayer Assistance Division at 1-877-252-3052 (toll free).
Seller: You are required to maintain proper records of exempt transactions and provide those records to Member
states of the SST Governing Board, Inc., when requested. These certicates may be provided in paper or electronic
format. If a paper exemption certicate is not forwarded by the purchaser, but instead the data elements required
on the form are otherwise captured by the seller, the seller must maintain such data and make it available to
Member states in the form in which it is maintained by the seller.
You are relieved of the responsibility for collecting and remitting sales tax on the sale or sales for which the
purchaser provided you with this exemption certicate, even if it is ultimately determined that the purchaser
improperly claimed an exemption, provided all of the following conditions are met:
1.
All elds on the exemption certicate are completed by the purchaser or the required information is captured
and maintained;
2.
The fully completed exemption certicate (or the required information) is provided to you at the time of sale
or as otherwise provided by Section 317 of the SSUTA;
3. If the purchaser is claiming an entity-based exemption (i.e., an exemption based on who the purchaser is),
the state that would otherwise be due the tax on the sale allows the specic entity-based exemption claimed
by the purchaser if the purchase was made at a sale location operated by the seller within that state;
4. You do not fraudulently fail to collect the tax due; or
5. You do not solicit customers to unlawfully claim an exemption.
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Form 1: Certicate of Exemption

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Completed 5 February 2021

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