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Multi - Jurisdiction *130563==19999* See page 2 for (Colorado DORA)

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DR 0563 (08/30/13)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0013
Sales Tax Exemption Certicate
Multi - Jurisdiction
See page 2 for instructions
Last Name or Business Name First Name Middle Initial
Address
City State ZIP
I Certify That
Name of Firm (Buyer)
Address
City State ZIP
Qualies As (Check each applicable item)
Wholesaler Retailer Manufacturer Charitable or Religious
Political Subdivision or Governmental Agency Other (Specify)
If Other, specify here
1) and is registered with the below listed states and cities within which your rm would deliver purchases to us
which are for resale or lease by us in the normal course of our business which is or
2) that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
Political Subdivision or Governmental Agency Charitable or Religious Otherwise Exempt By Statute (Specify)
If Otherwise Exempt By Statue, specify here
City or State State Registration or ID Number City or State State Registration or ID Number
City or State State Registration or ID Number City or State State Registration or ID Number
City or State State Registration or ID Number City or State State Registration or ID Number
General Description of products to be purchased from seller
Under penalties of perjury, I swear or afrm that the information on this form is true and correct as to every material matter.
Authorized Signature (owner, Partner or Corporate Ofcer) Title Date (MM/DD/YY)
1) and is registered with the below listed states and cities within which your rm would deliver purchases to us
Which are for resale or lease by us in the normal course of our business which is _________________________or
2) that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
If the list of states and cities is more than six(6), attach a list to this certicate.
I further certify that if any property so purchased tax free is used or consumed by the rm as to make it subject to a Sale or
Use Tax we will pay the tax due direct to proper taxing authority when state law so provides or inform the seller for added
tax billing. This certicate shall be part of each order which we may hereafter give to you, unless otherwise specied, and
shall be called until canceled by us in writing or revoked by the city or state.
*130563==19999*
In order to comply with the majority of state and local sales
tax law requirements, it is necessary that we have in our
les a properly executed exemption certicate from all of our
customers who claim sales tax exemption. If we do not have
this certicate, we are obligated to collect the tax for the state
in which the property is delivered. If you are entitled to sales
tax exemption, please complete the certicate and send it to
us at your earliest convenience. If you purchase tax free for
a reason for which this form does not provide, please send
us your special certicate or statement.
*Lessor: A form DR0440, “Permit to Collect Sales Tax
on the Rental or Lease Basis” must be completed and
submitted to the Department of Revenue for approval.
Caution To Seller: In order for the certicate to be
accepted in good faith by the seller, the seller must exercise
care that the property being sold is of a type normally
sold wholesale, resold, leased, rented , or utilized as an
ingredient or component part of a product manufactured by
the buyer in the usual course of his business. A seller failing
to exercise due care could be held liable for the sales tax
due in some states or cities.
Misuse of this certicate by the seller, lessor, buyer, les-
see, or the representative thereof may be punished by ne,
imprisonment or loss of right to issue certicates in some
states or cities.
To Our Customers:
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Multi - Jurisdiction *130563==19999* See page 2 for (Colorado DORA)

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Completed 14 January 2021

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