Tax Exemption Certification Form

Name of purchaser, firm or agency
Phone (Area code and number)
Address (Street & number, P.O. Box or Route number)
Email*
City, State, ZIP code

I, the purchaser named above, claim an exemption from payment of sales and use taxes (for the purchase of taxableitems described below or on the attached order or invoice) from:

Seller:
Street address:
City, State, ZIP code:
Description of items to be purchased or on the attached order or invoice:
Purchaser claims this exemption for the following reason:

I understand that I will be liable for payment of all state and local sales or use taxes which may become due for failure to comply with the provisions of the Tax Code and/or all applicable law.

understand that it is a criminal offense to give an exemption certificate to the seller for taxable items that I know, at the time of purchase, will be used in a manner other than that expressed in this certificate, and depending on the amount of tax evaded, the offense may rangefrom a Class C misdemeanor to a felony of the second degree.

Title:
Date:

NOTE: This certificate cannot be issued for the purchase, lease, or rental of a motor vehicle.
THIS CERTIFICATE DOES NOT REQUIRE A NUMBER TO BE VALID.
Sales and Use Tax "Exemption Numbers" or "Tax Exempt" Numbers do not exist.
This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts.

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