Tax Exemption Certificate

This is a multi-state form. Not all states allow all exemptions listed on this form. Purchasers are responsible for knowing if they qualify to claim exemption from tax in the state that would otherwise be due tax on this sale. The seller may be required to provide this exemption certificate (or data elements required on the form) to a state that would otherwise be due tax on this sale.
The purchaser will be held liable for any tax and interest, and possibly civil and criminal penalties imposed by the member state, if the purchaser is not eligible to claim this exemption. A seller may not accept a certificate of exemption for an entity-based exemption on a sale made at a location operated by the seller within the designated state if the state does not allow such an entity-based exemption.

1. Are you attaching the Multistate Supplemental form?*

Yes
No

If no, select the two-letter postal abbreviation for the state under whose laws you are claiming exemption.*

2. Is this certificate for a single purchase?*

Yes
No

If yes, enter the related invoice/purchase order #*

Personal Information

3. Name of purchaser*

Business Address*

City*

State*

Zip*

Purchaser's tax ID number

State of issue

Country of issue

If no tax ID number, enter one of the following:

FEIN

Driver's License Number

Driver's License State

Foreign Diplomat Number

Name of seller from whom you are purchasing, leasing, or renting*

Seller's address*

City*

State*

Zip*

Type of Business

Check the number that descripes your business

4. Type of Business*

You've selected, Type of Business: Other, please specify below.*

Reason for Exemption

Check the letter that identifies the reason for the expemtion.

5. Reason for Exemption*

You've selected, A Federal government (department), please enter the additional information requested for that exemption.*

You've selected, B State or local government (name), please enter the additional information requested for that exemption.*

You've selected, C Tribal government (name), please enter the additional information requested for that exemption.*

You've selected, D Foreign diplomat #, please enter the additional information requested for that exemption.*

You've selected, G Resale #, please enter the additional information requested for that exemption.*

You've selected, H Agricultural production #, please enter the additional information requested for that exemption.*

You've selected, I Industrial production/manufacturing #, please enter the additional information requested for that exemption.*

You've selected, J Direct pay permit #, please enter the additional information requested for that exemption.*

You've selected, K Direct mail #, please enter the additional information requested for that exemption.*

You've selected, L Other, please explain.*

Sign here

I declare that the information on this certificate is correct and complete to the best of my knowledge and belief.

Signature of authorized purchaser*

Date*

Print name here*

Title*

332 Atando Ave. | Charlotte, NC 28206
Mon - Fri: 8:00 am - 6:00 pm