DR 0563 (08/30/13)
      COLORADO DEPARTMENT OF REVENUE                                                                          *130563==19999*
      Denver CO 80261-0013

                                                           Sales Tax Exemption Certificate
                                                                       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

                                                              Qualifies As (Check each applicable item)
         Wholesaler                                           Retailer                    Manufacturer                         Charitable or Religious
 and is registered with the below listed states and cities within which your firm would deliver purchases to us 1)
         Political Subdivision or Governmental Agency                                     Other (Specify)
Which areIf Other,for resalespecify hereor lease by us in the normal course of our business which is _________________________or

 that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:2)
      1) and is registered with the below listed states and cities within which your firm 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

      If the list of states and cities is more than six(6), attach a list to this certificate.
      I further certify that if any property so purchased tax free is used or consumed by the firm 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 certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and 
      shall be called until canceled by us in writing or revoked by the city or state.
      General Description of products to be purchased from seller

      Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.
      Authorized Signature (owner, Partner or Corporate Officer)                       Title                                    Date (MM/DD/YY)

                                          To Our Customers:

In order to comply with the majority of state and local sales    Caution To Seller: In order for the certificate to be 
tax law requirements, it is necessary that we have in our        accepted in good faith by the seller, the seller must exercise  
files a properly executed exemption certificate from all of our  care that the property being sold is of a type normally 
customers who claim sales tax exemption. If we do not have       sold wholesale, resold, leased, rented , or utilized as an 
this certificate, we are obligated to collect the tax for the state  ingredient or component part of a product manufactured by 
in which the property is delivered. If you are entitled to sales the buyer in the usual course of his business. A seller failing 
tax exemption, please complete the certificate and send it to    to exercise due care could be held liable for the sales tax 
us at your earliest convenience. If you purchase tax free for    due in some states or cities.
a reason for which this form does not provide, please send 
us your special certificate or statement.                        Misuse  of this  certificate by the seller, lessor, buyer, les-
*Lessor: A form DR0440, “Permit to Collect Sales Tax             see, or the representative thereof may be punished by fine, 
on the Rental or Lease Basis” must be completed and              imprisonment or loss of right to issue certificates in some 
submitted to the Department of Revenue for approval.             states or cities.