Form: Tax Status Certificate for Sales and Use Tax Multi-Jurisdiction

Dear Prospective Customer:

In order to comply with state and local sales and use tax laws, it is necessary that we have a properly executed tax status certificate from all our customers. Please complete the following, sign at the bottom and return with your credit application. No credit will be approved without a completed tax certificate.

The undersigned purchaser, being fully informed concerning Sales and Use Tax Acts and their Rules and Regulations, hereby certifies that he is either legally subject to such taxes or is entitled to exemption from such taxes, by reason of one or more of the classifications listed below.
Sales Tax Status*
- Subject to State Sales and Use Tax
- Exempt, as Sales and/or Use Tax will be paid by us direct to State, based on actual usage
- Exempt, as equipment and parts are to be used in production and/or industrial processing
- Exempt, as equipment and parts are purchased for resale.
State*
Tax Registration Number*
The undersigned hereby certifies that if any property purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax the undersigned will pay the tax due direct to the proper taxing authority when the law so provides, inform the seller for added tax billing and/or reimburse the seller for any violations of rules and regulations. This certificate shall be part of each order, unless otherwise specified on such order and shall remain in effect until canceled by us in writing or revoked by the governing state.
General Description of products purchased from seller:*
The company is engaged as a registered:*
- Wholesaler
- Retailer
- Manufacturer
Company Name*
Your Name*
Address*
Street Address Address Line 2 City State ZIP Code
Signature*
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