REV-1715
REGISTRATION AND
TAXPAYER MANAGEMENT
PO BOX 280901
HARRISBuRG PA 17128-0901
(TR) 12-19
EXEMPT ORGANIZATION
DECLARATION OF SALES
TAX EXEMPTION
OFFICIAL USE ONLY
THIS FORM MAY BE PHOTOCOPIED
PURPOSE:
Vendors may use this declaration to document purchases of tax free items by tax exempt organizations (charitable, religious and educational
organizations and volunteer fire or ambulance companies) holding a valid exemption number issued by the Department of Revenue where the
purchase is $200 or more. The vendor may require the Customer’s Declaration (below) for each such transaction to demonstrate that the vendor
made the tax exempt sale “in good faith”.
INSTRUCTIONS:
Complete each declaration in its entirety. Use a separate declaration for each transaction of $200 or more. Accompany the declaration with an
invoice and a properly completed Exemption Certificate (REV-1220), and maintain these documents for three years.
IMPORTANT: Do not return this form to the Department of Revenue.
CUSTOMER’S DECLARATION
As an authorized representative of a tax-exempt organization, I declare that the property and/or services purchased or leased in the name of
the exempt organization set forth below, as described on the attached invoice, are being purchased for an exempt use under Pennsylvania
Sales Tax law.
VENDOR’S DECLARATION
I understand that this completed declaration must be kept in my records for three years from the purchase date. I understand that failure to
provide the declaration to Revenue auditors could result in my liability for Sales Tax if the transaction is subsequently determined to be taxable.
Attached is Invoice No. dated covering this exempt transaction.
Print Name
Name of Exempt Organization Phone Number Sales Tax Exemption No. (must have a 75-prefix)
Signature Title
Vendor Signature Date
