R-1079 (11/16)
                                                                                                  Louisiana Department of Revenue
                                    Purchases for Resale by Foreign Purchaser                     P.O. Box 201
                                                                                                  Baton Rouge, LA  70821-0201
                                           Louisiana R.S. 47:301(10)(a)(i)                        Telephone: (855) 307-3892
                                                                                                  www.revenue.louisiana.gov

                                                                                                                  PLEASE PRINT OR TYPE.
                                           Purchaser Information
Legal Name

Business Name

Mailing Address

City                                                                                        State  ZIP

Location Address

City                                                                                        State  ZIP

Please provide the following information:
Domicile State                                                        Domicile Tax Account Number

Domicile License Number                  Please check appropriate box:
                                         ■ Retail license number      ■ Wholesale license number  ■ Manufacturer’s license number

This certifies that all tangible personal property bought by the above-named purchaser is to be transported beyond the territorial limits 
of the State of Louisiana to be resold or further processed into new articles for sale at retail. Purchases for resale or further processing 
are exempt from state sales tax under the provisions of Louisiana Revised Statute 47:301(10)(a)(i). The purchaser hereby agrees that 
should this sale later be held subject to state sales tax, the purchaser assumes full liability for such tax.  

                                           Authorization
Under penalties of perjury, I declare that I have examined this exemption certificate and to the best of my knowledge and belief, it is 
true, correct and complete. 
Authorized Purchaser (please print)                                     Date (mm/dd/yyyy)

Signature                                                               Purchaser Title

                                           Seller Information
Seller Name

Location address

City                                                                                              State        Zip

                                           Applicable State Sales Tax Rates
                                    From                                To                                 Rate
                            4/1/16                                    6/30/16                              0%
                            7/1/16                                    6/30/18                              0%
                            7/1/18                                    3/31/19                              0%
                Notice to Seller: Report this sale on Schedule A, Line 29, sales for resale.
                CAUTION: Misuse of this exemption certificate will subject the purchaser or seller to payment of the tax and 
                all civil or criminal penalties provided for by Title 47 of the Louisiana Revised Statutes.