R-1042 (10_08)
Louisiana Resale Certicate
Sales Tax Exemption
Certicate for Purchases for Resale
R.S. 47:301(10)
Please print or type.
Purchaser Information
Name of purchaser, as shown on the sales tax account Sales Tax Account Number
(10 digits)
Address Telephone
( )
City State ZIP
Purchaser’s Type of Business
Description of purchaser’s business activity or items sold:
I, the purchaser, certify that all materials, goods, merchandise, and services purchased from the seller named below are for resale as
tangible personal property, either in the same form as purchased or to be added as a recognizable, identiable, and benecial component
of a new product. I further certify that all tax-exempt purchases will be resold in the normal course of our business.
I understand that if I use any of the items other than for resale, I must pay sales tax at the time of use. If this purchase is later found to be
subject to tax, I, the purchaser, assume full liability for the tax.
Seller Information
Seller
Address
(Street & number or P.O. Box)
City State ZIP
Any purchaser or agent who fraudulently signs this certicate without intent to use the taxable items for resale is subject to all the penalties
provided for by Title 47 of the Louisiana Revised Statutes and collection will be pursued against the seller or purchaser for any taxes,
penalties and interest due.
Purchaser’s Declaration
Name Title
Signature
X
Date (mm/dd/yyyy)
