R-1041 (7/18)
                                                                                                   Louisiana Department of Revenue
                                  Institutional or Retail Dealer Purchases of                      Revenue Processing Center
                                  Medical-Related Property                                         P.O. Box 4998
                                  Sales/Use Exemption Certificate                                  Baton Rouge, LA  70821-4998
                                                                                                   Phone: (855) 307-3893
                                  La. R.S. 47:305(D)(1) et.al.                                     Fax: (225) 237-6762

                                                                                                   PLEASE PRINT OR TYPE
                                  Vendor’s Information
Vendor Name

Address

City                                                                                               State           ZIP

This certifies that the tangible personal property on the attached list purchased from the above referenced vendor will be sold or dispensed 
to and fully consumed by the institution’s patients or the retail customers as:

Mark one or more, as applicable:

     Sales Return                                             Description
       Code

     Schedule A, 
■      Line 25    Drugs prescribed by physicians or dentists. (R.S. 47:305(D)(1)(j))  
■      5023       Orthotic, including prescription eyeglasses and contact lenses, and prosthetic devices and wheelchairs and wheelchair lifts 
                  prescribed by physicians, optometrists or licensed chiropractors for personal consumption or use. (R.S. 47:305(D)(1)(k))
                  Ostomy, ileostomy, or colostomy devices or appliances, including catheters or any related items, which are required as the result 
■      5024       of any surgical procedure by which an artificial opening is created in the human body for the elimination of natural waste. (R.S. 
                  47:305(D)(1)(l))
■      5027       Medical devices to be used personally and exclusively by the patients or retail customers in the medical treatment of various 
                  diseases under the supervision of and prescribed by registered physicians. (R.S. 47:305(D)(1)(s))
■      5028       Orthotic devices, prosthetic devices, prostheses, and restorative materials utilized or prescribed by dentists in connection with 
                  health care treatment or for personal consumption or use. (R.S. 47:305(D)(1)(t)) 

Notice to Seller: Report these sales on the appropriate sales tax return schedule using the above referenced sales tax 
exemption codes if applicable.
                                  Buyer’s Information
Buyer

Buyer’s Address

City                                                                                               State           ZIP

                                  Authorization
Authorized Representative                                     Title

Signature                                                     Date (mm/dd/yyyy)

Questions about the completion of this form should be sent to Sales.Inquiries@la.gov.

                           GENERAL INFORMATION

This form is for the completion and presentation to their vendors by medical institutions and retail dealers in lieu of payment 
of the state sales tax when making purchases of tangible personal property that the institutions or retail dealers will sell to 
patients or customers without the collection of the state sales tax, by application of one or more of the statutory exemptions 
listed above. Vendors will retain the form and attached tangible personal property list as documentation of the exemptions 
allowed to their customers.
This form cannot be used by medical institutions when making purchases of durable assets for institutional use, such as 
laboratory equipment, X-ray film, bedding, or wheelchairs for general patient use.