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                                Certification of Use and/or Deferred Sales Tax Paid 
                                                                      
                                                  SUBMIT THIS CERTIFICATE IN DUPLICATE 
                                                       
This statement is made for the purpose of relieving named seller from liability for collection and payment of the 
tax due on articles upon which use tax and/or deferred sales tax has already been paid directly to the 
Department of Revenue as listed below. 
 
Any items paid are to be indicated separately as to date and amount of tax paid. If any articles are purchased 
for resale, a Reseller Permit should be provided the seller per Washington Administrative Code 
(WAC) 458-20-102. 
 
The undersigned hereby certifies that he/she has paid directly to the Washington State Department of Revenue 
the full amount of all use or deferred sales tax due and payable by reason of use in said state of that certain 
tangible personal property heretofore purchased from: 
 
  Name of Seller                                     Address of Seller 
 
 and particularly described in the following invoices issued by said seller: 
 
  Invoice  Invoice        Purchase                                              Date     Tax Return   Amount 
     No.    Date          Price                   Articles Purchased          Tax Paid or Document        of Tax 
                                                                                                      
 NOTE: All tax still due and unpaid is to be remitted to the seller per chapter 82.08.050 Revised Code of 
 Washington (RCW). 
    
  Purchaser’s Firm Name:                                                           Purchaser’s Account ID 
                                                                        
  Purchaser’s Signature:                                                            
                                                                                   
  By:    Purchaser’s Name and Title (Please Print)  Date 
                                      FOR DEPARTMENT OF REVENUE USE ONLY 
                                                                          /              /                 
    Verified By                                                          Date                              
 
For tax assistance or to request this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users 
may use the Washington Relay Service by calling 711. 
 REV 31 0033 (02/23/18)                                                                             Print This Form