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                                   Standard Municipal Home Rule Affidavit of Exempt Sale 
                                   This form is provided by home rule municipalities within the State of Colorado to record 
                                   supporting information for any transaction on which an exemption from tax is claimed. The 
                                   form is maintained by the seller for tax-exempt sales.                                          
                                   Furnish this form to the seller. Do not return this form to the taxing jurisdiction. 
                                                                 Purchase DetailsPurchase for resale   - or -   Purchase for wholesale  (Qualifications may vary by jurisdiction – see instructions) 
           State license number (not FEIN number):                                           Expiration                                            
           Local license number (if applicable):                                             Issuing municipality:                                 
              ☐ I affirm items purchased are for resale/wholesale in the ordinary course of business.  Initial                     
 ☐ Purchase by charitable organization (Exemptions may vary by jurisdiction) 
           State tax-exempt number (not FEIN number):                                        
           Local tax-exempt number (if applicable):                                          Issuing municipality:                                 
       Payment information (required to meet one of the following): 
           ☐ Paid by cash and accompanied by a purchase order from the organization  
           ☐ Paid by check drawn on funds of the exempt organization  
           ☐ Paid by purchasing card bearing information of the exempt organization 
                   The embossed name of the card is:                                              
           ☐ Paid by commercial card not a personal credit card -  card’s last four digits:       
 ☐ Purchase for federal, state, or local government 
      Credit card number (first six and last four only:________-_______XX-XXXX-________      
      Federal government (payment information – required to meet one of the following): 
           ☐ GSA SmartPay2 card – fleet card with picture of a road and flag 
           ☐ GSA SmartPay2 card – purchase card with picture of a keyboard and flag 
           ☐ GSA SmartPay2 card – travel card with picture of an airplane and flag 
           ☐ GSA SmartPay2 card – integrated card with picture of an eagle and flag 
           ☐ Dept of Interior agency issued card – agency name                                                           
      State and local government  (payment information – required to meet one of the following): 
           ☐ Paid by cash and accompanied by purchase order issued by the government agency 
           ☐ Paid by check issued by and drawn on funds from the government agency 
           ☐ Paid by government purchase card as designated on the card 
                   State tax-exempt number printed on the card (Colorado only):                                          
                   ☐ Check if the card states “for official state use only” or “tax exempt” 
 ☐ Purchase for foreign and diplomatic exemptions (required to meet the following): 
           ☐ Purchaser presents a state department issued card with the name/photo of the bearer on the card.   
                If presented with this card, documentation of form of payment is not required (excluding mission card). 
 ☐ Other qualified exemption 
           Nature of exemption:                                                                  Exempt number:                                             
 
                                                                Purchaser Information 
 Legal Name of Company/Organization/Agency Name                                                                  Purchaser Name (Printed) 
                                                                                                                  
 Address                                                              City                                                    State       Zip + 4 
  
 Phone                           Government      Issued ID #          Description of Normal Course of Business 
                                  
 Under penalty of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.  I affirm that the 
 items purchased tax-exempt will be used for official business of the above-named organization or agency.  I accept that I remain directly liable 
 for the taxes and any applicable penalty or interest if my purchase is found to not qualify for the exemption or if the information asserted in this 
 form is deemed fraudulent. 
 Signature                                                                                                               Date 
  
                                                                 Seller  Verification 
 Seller Name                                          Location #      Date                   Transaction ID                        Employee ID# / Initials 
  
 Description of Items Purchased or Attach Duplicate Receipt/Invoice                                                      Exempted Amount of Purchase 
  
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                                                         Instructions for Standard Municipal Home Rule Affidavit of Exempt Sale 
 
                                                         These instructions are specific to the jurisdiction in which this purchase has been made.  
 
                                                         Qualifying for an exemption may be different for each jurisdiction, and these instructions are not 
                                                                                                                                                                                  
                                                         intended to set forth the requirements of any jurisdiction other than the one indicated.   
                                                                                                                                                                                  
                         General Instructions                                                                        Seller Instructions 
                                                                                             
 Purpose of Form                                                                            Sellers have the burden of proving that a transaction was properly 
                                                                                            exempted.    If an exemption is subsequently disallowed by the 
 This form is used to certify  to sellers that  a purchase qualifies for                    municipality, you (the seller) could be liable for the tax plus penalties 
 exemption under Chapter 1 of Title 3 of the Breckenridge Town Code.                        and interest. This form is provided to help  you determine if a sale 
 For Sellers, accepting and keeping this document helps  you obtain                         qualifies  for  exemption. The sale is not exempt from taxes simply 
 correct information about the purchaser, which helps you prove this is                     because this affidavit is completed. The responsibility for proper 
 an exempt sale during a tax audit.                                                         collection of taxes remains with the seller. You are encouraged to 
                                                                                            obtain this form for each transaction and complete all of the information 
 For Purchasers, completing this document and giving it to seller helps                     in the lower Seller Verification section.  
 to speed up your purchase process. 
                                                                                            Resale/Wholesale transactions. To qualify as an exempt purchase for 
 Reminders                                                                                  resale or wholesale, the items purchased must be reasonably deemed 
         to be for sale in the ordinary course of business of the purchaser.  For 
 Furnish to seller. This form should be furnished to the seller charging                    resale/wholesale transactions the seller is required to not only collect 
 the tax. Do not send this form to the taxing jurisdiction. This form is not                the applicable license information, but to exercise sound judgment and 
 for organizations to request certification of their tax-exempt status.                     a reasonable amount of skepticism to ensure the items purchased are 
 Direct payment required.    Purchases must be billed to and paid                           reasonably for sale in the purchaser’s ordinary course of business.   For 
 directly by the funds of the organization or agency in order to qualify for                example, a restaurant would not be allowed to purchase dish soap for 
 exemption. Payment in cash (without a purchase order) or by personal                       resale because restaurants do not sell dish soap in the ordinary course 
 check or personal credit card disqualifies a purchase from exemption                       of business, but rather use the  dish soap in the operation of the 
 even if the purchaser is subsequently reimbursed. Purchases made on                        business.   
 credit cards  issued by the organization, but where the cardholder                         The affidavit  needs to be  completed in  its entirety.  Be  sure 
 receives and pays the bill and is subsequently reimbursed, also do not                     information is complete, accurate and legible. Review the information, 
 qualify for exemption.                                                                     and particularly verify that the driver’s license number and purchaser’s 
 Reimbursement disqualifies exemption.                   If the organization or             name are correct.  Also, be sure that the digits that are required from 
 agency  will be reimbursed, in whole or in part, the purchase is                           the credit cards are correct.  Only record and keep those digits from the 
 disqualified from exemption. For example, the purchase of food for a                       credit card that the affidavit requires.  The signature of the purchaser 
 banquet for which the organization sells tickets as a fundraiser would                     should be the same as on the driver license.  
 not qualify for exemption.                                                                 Sellers should review guidance on accepting government credit 
 Disputed tax  must be  collected.                       If there is a dispute between  the cards.  Not all cards qualify for exemption, even though they bear 
 purchaser and the seller as to whether tax applies, Chapter 1 of Title 3                   certain of the listed characteristics. 
 of the Breckenridge Town Code  requires the seller to collect the tax.                     Collection of this form does not provide a safe-harbor from 
 The seller must give the purchaser a receipt showing the tax collected.                    disallowance  by the municipality.         Retain this form for  at least 3 
 The purchaser may apply to the applicable  municipality directly for a                     years. 
 refund by filing a Claim for Refund form. 
 Signature required. The individual making the purchase must sign and 
 date the form at the bottom. A separate affidavit may be required for                                      Jurisdiction Specific Instructions 
 each transaction. General purchaser or store information  may be                           Wholesale Sales. Sales to licensed retailers, jobbers, dealers or 
 completed in advance and kept on file by the seller or purchaser for                       wholesalers for resale. Sales by wholesalers to consumers are not 
 ease of use.                                                                               wholesale sales. Sales by wholesalers to nonlicensed retailers are not 
                                                                                            wholesale sales.(see also exemption 3-1-4(M)) 
                         Purchaser Instructions                                             State License Number. State Tax Exempt Number. State and Local 
                                                                                            Government. Paid by government purchase card as designated on the 
 Purchase details. Identify the accurate qualified exemption reason and                     card. Out of state licenses are accepted. However, it is required that you 
 complete the required information for that exemption.                                      note the State abbreviations next to the required #, if other than Colorado. 
                                                                                            Ex. STATE LICENSE NUMBER (NOT FEIN NUMBER) KS 05-14322-0000  
 Purchaser information. Print the legal name of the organization or                               STATE TAX EXEMPT NUMBER TX 09803970  
 agency. Governmental agencies should include both the name of the                                STATE TAX EXEMPT NUMBER PRINTED ON THE CARD TX 09803970 (not printed on card) 
                                                                                             
 government and the department or agency,  for example, US                                  Other Qualified Exemption. Other exemption reasons included in the 
 Department  of Transportation, Colorado Department of Education, or                        Chapter 1 of Title 3 of the Breckenridge Town Code, but not separately 
 Adams  County Human Services. Abbreviations such as “Dept.” are                            listed on this form:  
 acceptable but do not use acronyms. List the organization’s or agency’s 
 mailing address, municipality, state, and zip code.                                        Schools. All sales made to schools, other than schools held or 
                                                                                            conducted for private or corporate profit. 
 Expedite purchase.  Purchase details and purchaser information may 
 be completed in advance and the partially completed form kept on file                      Exempt Construction Materials. All sales of construction materials to 
 by the purchaser for completion at time of each transaction.                               contractors and subcontractors for use in the building, erection, 
 Declaration of affiant. The individual making the purchase on behalf of                    alteration, or repair of structures, highways, roads, streets, and other 
 the exempt organization or  agency (the affiant) must complete the                         public works owned and used by: The United States government, the 
 declaration.                                                                               state, its departments and institutions, the political subdivisions thereof 
                                                                                            in their governmental capacities only; Charitable organizations, as 
 Signature.  You are swearing, under penalty of perjury, to the accuracy                    defined in section 3-1-2 of this chapter, in the conduct of their regular 
 of the statements made in this affidavit. Carefully     read and ensure that               charitable functions and activities; or Schools, other than schools held 
 you understand each item before signing this affidavit.  After reviewing                   or conducted for private or corporate profit. 
 the form for accuracy, sign and date the form.  Furnish this form to the                   FOR THE FULL TEXT OF APPLICABLE DEFINTIONS AND EXEMPTIONS, 
 seller.  Do not send a copy to the municipality.                                           PLEASE SEE BRECKENRIDGE TOWN CODE 3-1-4. 
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