REV-1715 AS (10-05)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXESEXEMPT ORGANIZATION
PO BOX 280901
HARRISBURG, PA 17128-0901 DECLARATION OF
                          SALES TAX EXEMPTION

                                     THIS FORM MAY BE PHOTOCOPIED

INSTRUCTIONS:
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.”
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.
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.

Authorized Signature

                                   (  )
Print Name/Title                                                                                                                    Phone No.

Name of Exempt Organization                                                                                                         Sales Tax Exemption No.
                                   (Must have a 75-prefix)

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.

                                   Vendor’s Signature