(TR) 12-19 
                                                                                OFFICIAL USE ONLY
               REV-1715 
               REGISTRATION AND           EXEMPT ORGANIZATION 
               TAXPAYER MANAGEMENT        DECLARATION OF SALES 
               PO BOX 280901 
               HARRISBuRG PA  17128-0901  TAX EXEMPTIONTHIS FORM MAY BE PHOTOCOPIED 

PURPOSE: 
Vendors may use this declaration to document purchases of tax free items by tax exempt organizations (charitable, religious and educational 
organizations and volunteer fire or ambulance companies) holding a valid exemption number issued by the Department of Revenue where the 
purchase is $200 or more. The vendor may require the Customer’s Declaration (below) for each such transaction to demonstrate that the vendor 
made the tax exempt sale “in good faith”. 
INSTRUCTIONS: 
Complete each declaration in its entirety. Use a separate declaration for each transaction of $200 or more. Accompany the declaration with an 
invoice and a properly completed Exemption Certificate (REV-1220), and maintain these documents for three years. 

IMPORTANT: Do not return this form to the Department of Revenue. 

CUSTOMER’S DECLARATION 
As an authorized representative of a tax-exempt organization, I declare that the property and/or services purchased or leased in the name of 
the exempt organization set forth below, as described on the attached invoice, are being purchased for an exempt use under Pennsylvania 
Sales Tax law. 
 Print Name                                Signature                             Title
                                                             SIGN AFTER PRINTING
 Name of Exempt Organization               Phone Number Sales Tax Exemption No. (must have a 75-prefix)

VENDOR’S DECLARATION 
I understand that this completed declaration must be kept in my records for three years from the purchase date. I understand that failure to 
provide the declaration to Revenue auditors could result in my liability for Sales Tax if the transaction is subsequently determined to be taxable. 
                                          MM/DD/YYYY
Attached is Invoice No.                                                   dated                              covering this exempt transaction. 
 Vendor Signature                                                                                                                               DateMM/DD/YYYY
                                          SIGN AFTER PRINTING

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