STATE OF ARKANSAS 
               DEPARTMENT OF FINANCE AND ADMINISTRATION 
               SALES AND USE TAX SECTION 
                                       
               EXEMPTION CERTIFICATE 
               GR-53 & AR Code 26-52-517(b)(1), (e), and (f) 
 
I hereby certify that I either hold or am the authorized representative of the holder of 
Arkansas Sales/Use Tax Permit Number               , or that I am a 
nonresident purchaser or the authorized representative thereof and hold a similar permit 
issued by the State of           , Number          , that this is a 
current and valid permit number; and that I am exempt from sales and use tax on the 
tangible personal property purchased from                    
 
I further certify that if any tangible personal property purchased exempt under this 
certificate is withdrawn from stock or otherwise used, that I will report the tax due under 
Arkansas Sales/Use Tax Law and Rules. 
 
Description of the merchandise to be purchased: (Please give a specific identification of 
items purchased. If needed an additional statement may be attached hereto.)          
 
The merchandise purchased is exempt for the following reason:            
 
Purchaser's business activity:                         
 
   ______________________________________________________________ 
 
Purchaser's Business Name (as stated on permit)    Purchaser's Signature 
 
Address            Title/Position with Company 
  
City, State, Zip          Date 
 
Notice to sellers: A seller who follows all applicable exemption requirements is relieved from any 
tax even if it is determined that the purchaser improperly claimed an exemption. However, if the 
seller fraudulently fails to collect the sales tax, solicits a purchaser to participate in an unlawful 
claim of an exemption, or accepts an entity-based exemption for  which an exemption is not 
available in the State of Arkansas, the seller  will be responsible for the sales tax due on the 
transaction. 

ST391 
REV 01/01/2008