01-374                                                                     PRINT FORM CLEAR FORM
  (Rev.5-09/2)

TEXAS MAQUILADORA EXEMPTION CERTIFICATE –                                    Maquiladora exemption permit number
	 LIMITED	SALES,	EXCISE	AND	USE	TAX
Name of purchaser

Street address

City, state, ZIP Code

  The undersigned hereby claims exemption from the payment of state and local taxes on its purchases of taxable items  
  for export to Mexico from:

  Seller:     ________________________________________________________________________________________

  Street address:     _________________________________________________________________________________

  City, state, ZIP Code :  ____________________________________________________________________________

  This certificate will remain in effect until the seller is otherwise notified and does not cover purchases of taxable items 
  to be resold in the form in which they are purchased. 
  The undersigned agrees to accrue and pay tax to the Texas Comptroller of Public Accounts on any goods purchased 
  under this certificate that are not exported to Mexico prior to their use. 
  This certificate is not valid unless accompanied by a copy of the Maquiladora Export Permit issued by the 
  Texas Comptroller of Public Accounts.
Name of permit holder (Type or print)  Authorized signature                  Date