R-1072 (9/12)
                                Manufacturer’s Designation of Mandate
                                    Louisiana R.S. 47:301(3)(i), 47:301(13)(k),  
                                               and 47:301(28)

Mandate Effective Date (mm/dd/yyyy)                                        Mandate Expiration Date (mm/dd/yyyy)

Legal Name                                                                                                     Louisiana Tax Account Number

Trade Name

Address

City                                                                                               State       ZIP

I, the above named manufacturer does hereby designate the following person as its mandatary for the purpose of making purchases, leases, and rentals 
of manufacturing machinery and equipment:

Name                                                                                                           Louisiana Tax Account Number

Address

City                                                                                                                    State ZIP

This designation of mandate shall be effective for purchases, leases, and rentals of manufacturing machinery and equipment to be used by the designating 
manufacturer predominantly and directly in manufacturing or producing tangible personal property or agricultural products for sale. The manufacturing 
machinery and equipment will be used at a plant facility whose address is: 

Address

City                                                                                                                       State    ZIP

Mark one.

 The designated mandatary is not restricted as to vendor.

 The designated mandatary is restricted to purchases from the following vendor:

Purchases, leases, and rentals of tangible personal property during this period by the mandatary for use at this manufacturing location shall be considered 
as the legal equivalent of purchases directly by the designating manufacturer. Should such tangible personal property ultimately be used other than 
predominately and directly in the manufacturing of tangible personal property or agricultural products for sale, the designating manufacturer and/or the 
designated mandatary will be liable for the tax. The mandatary is not authorized to delegate this purchasing authority to others; separate designations 
of mandate by the manufacturer are required for each person who is to purchase eligible manufacturing machinery and equipment on behalf of the 
manufacturer. The undersigned hereby certify that this designation is the entirety of the mandate contract between them.

                    Designation of Agency                                        Acceptance of Agency
Authorized Designator Signature                Date (mm/dd/yyyy) Contractor or Subcontractor Authorized Acceptor Signature       Date (mm/dd/yyyy)

Authorized Designator’s Name                                     Mandatary’s Authorized Acceptor Name

Manufacturer’s Name                                              Mandatary Name

Address                                                          Address

City                                     State ZIP               City                                                   State    ZIP