R-1041 (8/16)

                                Institutional or Retail Dealer Purchases of                                           Louisiana Department of Revenue
                                Medical-Related Property                                                              Revenue Processing Center
                                                                                                                      P.O. Box 4998
                                Sales/Use Exemption Certificate                                                       Baton Rouge, LA  70821-4998
                                La. R.S. 47:305(D)(1) et.al., 47:305.2, and 47:315.3                                  Phone: (855) 307-3893

                                                                                                                      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:
                                                                                                                      Tax Rate  Tax Rate   Tax Rate 
     Sales Return               Description                                                                           4/1/2016- 7/1/2016-  7/1/2018-
       Code                                                                                                           6/30/2016  6/30/2018 3/31/2019
     Schedule A, 
■      Line 25    Drugs prescribed by physicians or dentists. (R.S. 47:305(D)(1)(j))                                  0%           0%          0%
                  Orthotic, including prescription eyeglasses and contact lenses, and prosthetic devices 
■      5023       and wheelchairs and wheelchair lifts prescribed by physicians, optometrists or licensed             5%           0%          0%
                  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 
■      5024       items, which are required as the result of any surgical procedure by which an artificial open-      5%           0%          0%
                  ing is created in the human body for the elimination of natural waste. (R.S. 47:305(D)(1)(l))
■      5025       Patient aids prescribed by physicians or licensed chiropractors for home use. (R.S. 47:305(D)(1)(m) 5%           3%          0%
                  Medical devices to be used personally and exclusively by the patients or retail customers 
■      5027       in the medical treatment of various diseases under the supervision of and prescribed by             5%           3%          0%
                  registered physicians. (R.S. 47:305(D)(1)(s))                         
                  Orthodox devices, prosthetic devices, prostheses, and restorative materials utilized 
■      5028       or prescribed by dentists in connection with health care treatment or for personal                  5%           3%          0%
                  consumption or use. (R.S. 47:305(D)(1)(t))
■      5036       Sales of nonprescription insulin, for personal consumption or use. (R.S. 47:305.2)                  5%           3%          0%
■      7015       Tangible personal property provided to a patient in a sale, lease or rental transaction, and        0%           0%          0%
                  for which the provider is entitled to payment by or under Medicare. (R.S. 47:315.3)

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.