Streamlined Sales Tax Agreement
Certificate of Exemption
Do not send this form to the Streamlined Sales Tax Governing Board. Send
the completed form to your supplier and keep a copy for your records.
This is a multi-state form. Not all states allow all exemptions listed on this form. Purchasers are responsible for knowing if they qualify to
claim exemption from tax in the state that would otherwise be due tax on this sale. The seller may be required to provide this exemption
certificate (or the data elements required on the form) to a state that would otherwise be due tax on this sale.
The purchaser will be held liable for any t ax and interest, and possible civil and criminal penalties imposed by the member state, if
the purchaser is not eligible to claim this exemption. A seller may not accept a certificate of exemption for an entity-based exemption on a
sale made at a location operated by the seller within the designated state if the state does not allow such an entity-based exemption.
Check if you are attaching the Multistate Supplemental form.
1.
If not, enter the two-letter abbreviation for the state under whose laws you are claiming exemption.
2. Check if this certificate is for a Single Purchase Certificate. Enter the related invoice/purchase order # _______________.
A. Name of purchaser
3.
B. Business address City State Zip code
C. Purchaser’s tax ID number State of Issue Country of Issue
D. If no tax ID number, enter one of the following: FEIN
E. Driver ’s License Number/State Issued ID number State of Issue
Print or type
F. Foreign diplomat number
G. Name of seller from whom you are purchasing, leasing or renting
H. Seller’s address City State Zip code
Purchaser’s Type of business. Circle the number that best describes your business.
4.
01 Accommodation and food services 11 Transportation and warehousing
02 Agriculture, forestry, fishing, hunting 12 Utilities
03 Construction 13 Wholesale trade
04 Finance and insurance 14 Business services
05 Information, publishing and communications 15 Professional services
06 Manufacturing 16 Education and health-care services
07 Mining 17 Nonprofit organization
08 Real estate 18 Government
Circle type of business 09 Rental and leasing 19 Not a business
10 Retail trade 20 Other (explain)
Reason for exemption. Circle the letter that identifies the reason for the exemption.
5.
reason A Federal government (Department) H Agricultural Production #
B State or local government (Name) I Industrial production/manufacturing #
C Tribal government (Name) J Direct pay permit #
exemption
or check D Foreign diplomat # K Direct Mail #
for E Charitable organization # L Other (Explain)
Circle F Religious organization # M Educational Organization #
G Resale #
I declare that the information on this certificate is correct and complete to the best of my knowledge and belief.
6.
Sign here Signature of authorized purchaser Print name here Title Date
SSTGB Form F0003 Exemption Certificate (Revised 5/10/2017 for use 1/1/2018)