Standard Municipal Home Rule Affidavit of Exempt Sale 
                                                                                          This form is required by home rule municipalities within the State of Colorado for any 
                                                                                          transaction on which an exemption from tax is claimed. The seller is required to maintain a 
                                                                                          completed form for each tax-exempt sale.                                          
                                                                                          Furnish this form to the seller. Do not return this form to the taxing jurisdiction.
                                               ☐ PURCHASE 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 RELIGIOUS OR 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 BY 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 
                 Purchase Details                        ☐ 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 BY 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: _____________________ 
                                                                                                                                                
                                               LEGAL NAME OF COMPANY/ORGANIZATION/AGENCY NAME                                                  PURCHASER NAME (PRINTED) 
                                                                                                                                                
                                               ADDRESS                                                                   CITY                                               STATE ZIP + 4 
                                                                                                                          
                                               PHONE                                     STATE  / DRIVERS LICENSE #      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 
                 Purchaserasserted                            Informationin this form is deemed fraudulent.                                             
                                               SIGNATURE                                                                                               DATE 

                                                 SELLER NAME                                                  LOCATION #  DATE          TRANSACTION ID                       EMPLOYEE ID# / INITIALS 

        Seller                                   DESCRIPTION OF ITEMS PURCHASED OR ATTACH DUPLICATE RECEIPT/INVOICE                                      EXEMPTED AMOUNT OF PURCHASE 
                                  Verification 

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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.   
                                                                                                                                                                                                                                                                                 
                                              Purpose of Form                                                                                                                                           Sellers have  the burden of  proving that a transaction  was             
                                                                                                                                                                                                        properly exempted.     If an exemption is subsequently disallowed 
                                              This form is used to certify to sellers that a purchase qualifies for                                                                                     by the municipality, you (the seller) could be liable for the tax plus 
                                              exemption under Fort Collins Municipal Code (FCMC) Chapter 25.                                                                                            penalties and interest. This form is provided to help  you 
                                                                                                                                                                                                        determine  if a sale qualifies for exemption. The sale is  not 
                                                                                                                                                                                                        exempt  from  taxes simply because this affidavit is completed. 
                                              Reminders                                                                                                                                                 The responsibility for proper collection of taxes remains with the 
                                              Furnish to seller. This form  should be furnished to the seller                                                                                           seller. You are encouraged to obtain this form for each 
                                              charging the tax. Do not send this form to the taxing jurisdiction.                                                                                       transaction and complete all of the information in the lower Seller 
                                              This form is not for organizations to request certification of their tax                                                                                  Verification section.  
                                              exempt status.                                                                                                                                            Resale/Wholesale transactions – To qualify as an exempt 
                                              Direct payment required.   Purchases must be billed to and paid                                                                                           purchase for resale or wholesale, the items purchased must be 
                                              directly by  the funds of the organization or agency in order to                                                                                          reasonably deemed to be for sale in the ordinary course of 
                                              qualify for exemption. Payment in cash (without a purchase order)                                                                                         business of the purchaser.  For resale/wholesale transactions the 
         or by personal check or personal credit card disqualifies a                                                                                                                                    seller is required to not only  collect the  applicable license 
                                              purchase from exemption even if  the purchaser is subsequently                                                                                            information, but to exercise sound judgment and a reasonable 
                                              reimbursed. Purchases made on credit cards issued by  the                                                                                                 amount of skepticism to ensure the items purchased  are 
                                              organization, but where the cardholder receives and pays the bill                                                                                         reasonably  for sale in the purchaser’s ordinary course of 
                                              and is subsequently reimbursed, also do not qualify for exemption.                                                                                        business.   For example, a restaurant would not be allowed  to 
                                                                                                                                                                                                        purchase dish  soap for resale because restaurants do not sell 
                                              Reimbursement disqualifies  exemption.  If  the organization or                                                                                           dish soap in the ordinary course of business, but rather use the 
                                              agency  will be  reimbursed, in  whole or in part,  the purchase is                                                                                       dish soap in the operation of the business.   
                       General Instructions   disqualified from exemption. For example, the purchase of food for                                                                    Seller Instructions 
                                              a banquet for which the organization sells tickets as a fundraiser                                                                                        The affidavit needs to be completed in its entirety.  Be sure 
                                              would not qualify for exemption.                                                                                                                          information is complete, accurate and legible. Review the 
                                                                                                                                                                                                        information, and particularly  verify that  the driver’s license 
                                              Disputed tax must be collected. If there is a dispute between the                                                                                         number and purchaser’s name are correct.  Also, be sure that the 
                                              purchaser and the seller as to whether tax applies, FCMC Section                                                                                          digits that are required from the credit cards are correct.   Only 
                                              25-73 requires the seller to collect the tax. The seller should give                                                                                      record and keep those digits from the credit card that the affidavit 
                                              the purchaser a receipt showing the tax collected. The purchaser                                                                                          requires.  The signature of the purchaser should be the same as 
                                              may apply to the applicable  municipality directly  for a refund by                                                                                       on the driver’s license.  
                                              filing a Claim for Refund form along with the appropriate 
                                              documentation within 60 days of the date of the purchase.                                                                                                 Sellers should review  guidance on accepting government 
                                                                                                                                                                                                        credit cards.  Not all cards qualify for exemption, even though 
                                              Signature required. The individual making the purchase must                                                                                               they bear certain of the listed characteristics. 
                                              sign and date the form at  the bottom. A separate affidavit is 
                                              required for each transaction. General purchaser or store                                                                                                 Collection of this form does not provide a safe-harbor from 
                                              information may be completed in advance and kept on file by the                                                                                           disallowance by the municipality.       Retain this form for at least 3 
                                              seller or purchaser for ease of use.                                                                                                                      years. 
                                                                                                                                                                                                         
                                              Purchase details.  Identify  the accurate qualified exemption                                                                                             Resale/Wholesale – The seller must obtain a copy of the 
                                              reason and complete the required information for that exemption.                                                                                          purchaser’s State of Colorado and applicable municipal resale or 
                                              Purchaser information. Print the legal name of the organization                                                                                           wholesale license or license number. To qualify as a tax exempt 
                                              or agency. Governmental agencies should include both the name                                                                                             resale/wholesale purchase the seller must exercise due care and 
                                              of the government and the department or agency, for example, US                                                                                           good faith to ensure the item/service sold is of a type normally 
                                              Department of Transportation, Colorado Department of Education,                                                                                           resold in the purchaser’s usual course of business. When in 
                                              or Adams County Human Services. Abbreviations such as “Dept.”                                                                                             doubt, it is the seller’s responsibility to collect tax. 
                                                                                                                                                                                                         
                                              are acceptable but do not use acronyms. List the organization’s or                                                                                        Charitable/Religious – To make purchases that are exempt 
                                              agency’s mailing address, municipality, state, and zip code.                                                                                              from City of Fort Collins tax, charitable/religious organizations 
                                              Declaration of affiant.   The  individual making the purchase on                                                                                          must provide a copy of the City of Fort Collins tax exemption 
                                              behalf of the exempt organization or agency (the affiant) must                                                                                            license or number to the seller.  
                                              complete the declaration.                                                                                                                                  
                                              Separate form required.  A separate affidavit is required for each                                                                                        Government – The seller must obtain a copy of the purchaser’s 
                                              transaction. For ease of use, Purchase  Details and Purchaser                                                                                             State of Colorado exemption certificate or certificate number. 
                                              Information may be completed in advance and the partially                                                                                                 Government sales include sales to public schools. The City does 
                                              completed form kept on  file by  the purchaser for completion at                                                                                          not issue a separate license for government/school entities. 
                                              time of each transaction.                                                                                                                                  
                                                                                                                                                                                                        Constructions Materials – If a city tax has been prepaid on a 
                       Purchaser Instructions Signature.    You are swearing, under penalty of perjury, to  the                                                                                         building permit, building materials purchased for the permitted 
                                              accuracy of the statements made in this affidavit. Carefully read                                                                                         project will be exempt from City of Fort Collins tax. The seller 
                                              and ensure that  you understand each item  before signing  this                                    Jurisdiction Specific Instructions                     must maintain a copy of the building permit. 
                                              affidavit.  After reviewing the form for accuracy, sign and date the                                                                                       
                                              form.  Furnish this form to the seller.  Do not send a copy to the                                                                                        For the full text of applicable definitions and exemptions refer to 
                                              municipality.                                                                                                                                             the FCMC Chapter 25. For assistance contact the Tax Division at 
                                                                                                                                                                                                        970-221-6780 or visit www.fcgov.com/salestax.  

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