Arizona Department of Revenue
                                               Application for Direct Payment Permit
                                      for Use Tax on Tangible Personal Property

                 1)     Federal Employer ID No. :         - - - -

                 2)     Arizona TPT License No. :         - - - -

                 3)     Legal Business Name:   

                 4)     Trade Name (DBA Name): 

                 5) Business Location in AZ:  Street 
                        (Not PO Box Number)
                                      City                                                 Zip 

                 6) Mailing Address:  

                        City, State, ZIP Code: 

                 7)     Type of Business:   

                 8)     Dollar amount of annual purchases in the preceding calendar year: 

                 9)     Principal reason for requesting a direct payment permit:

                 A)         The place of business where the property will be used is not known at the time of purchase.

                            Provide an example: 

                 B)         The manner in which the property will be used is not known at the time of purchase.

                            Provide an example: 

                 This application must be signed by one of the following: an owner, partner, corporate offi cer or association member.

                 Signature:                                                                Date: 

                 Name (Print): 

                 Title:                                                                    Phone: 

                 Mail to:   Arizona Department of Revenue
                            License & Registration Section
                            1600 W Monroe
                            Phoenix  AZ  85007-2650

                 ADOR 60-5405  (11/02)
60-5405.indd   1                                                                                                                     5/12/2006   11:34:12 AM

                                         General Information

                 Under the provisions of ARS § 42-5167, a use tax direct payment permit may be issued to a taxpayer 
                 that has annual out-of-state purchases of tangible personal property that exceeds $500,000 during the 
                 immediately preceding calendar year.  A valid use tax permit will allow the holder to self-assess and pay 
                 directly to the Department the use tax due for all tangible personal property subject to use tax.  The permit 
                 will be effective upon the date it is issued by the Department.  A vendor subject to Transaction Privilege 
                 Tax shall not accept a Direct Payment Permit to relieve the vendor of its liability for Transaction 
                 Privilege Tax.

                 Upon approval, the Department will issue a numbered direct payment permit.  The permit holder should 
                 issue a copy of the permit to an out of state vendor of tangible personal property with a completed 
                 Arizona Form 5000 identifying the reason on line 19, as “Direct Payment Permit” and including the permit 
                 number issued.  An out-of-state vendor that accepts a completed Arizona Form 5000 and a copy of the 
                 Department’s issued Direct Payment Permit is relieved of the responsibility to collect and remit Arizona use 
                 tax due on sales of tangible personal property to the permit holder.  (See TPP 00-3, for the proper use of 
                 exemption certifi cates).  The permit holder is liable for accruing and remitting the applicable Arizona use 
                 tax to the Department.  The Department will publish a list of Use Tax Direct Payment Permit holders 
                 and their TPT license number on its Internet website.

                 The Department may revoke a direct payment permit if the permit holder does not fi le a TPT-1 on time, 
                 does not pay the use tax on time, or otherwise fails to comply with the Transaction Privilege and Use Tax 
                 Laws.

                 If you have questions, you may contact the Arizona Department of Revenue, License & Registration 
                 Section, 1600 W Monroe, Phoenix  AZ  85007-2650.  Phone number is (602) 542-4576.  Information can 
                 also be obtained from the Internet at www.revenue.state.az.us.

                                         Line by Line Instructions

                 1)  Enter your business’s Federal Employer Identifi cation Number (FEIN).
                 2)  Enter your business’s Arizona Transaction Privilege Tax License number.  A separate application must 
                 be completed for each TPT license number.
                 3)  Enter the Legal Business Name for which a Direct Payment Permit is requested.
                 4)  Enter the Trade Name (DBA Name) for which a Direct Payment Permit is requested.
                 5)  Enter the physical address for your business in Arizona.  For multiple locations that use the same TPT 
                 license number, attach a sheet and list the trade names and business locations in Arizona.
                 6)  Enter the mailing address to which all correspondence regarding the Direct Payment Permit should be 
                 mailed.
                 7)  Describe the type of business you operate.
                 8)  Enter the amount of the preceding calendar year purchases of tangible personal property made by 
                 your business.
                 9)  Select the principal reason for requesting a Direct Payment Permit and give a specifi c example that 
                 supports your reason.

                 Sign and date the application.  This application must be signed by one of the following:  an owner, partner, 
                 corporate offi cer, or association member.  Print your name, title and phone number where you can be 
                 contacted if we have questions regarding your application.  Mail your completed application to the Arizona 
                 Department of Revenue, License & Registration Section, 1600 W Monroe, Phoenix  AZ  85007-2650.

                 ADOR 60-5405  (11/02)
60-5405.indd   2                                                                                           5/12/2006   11:34:40 AM