Exemption Certificate
(For use by States and local governments. (section 4041(g)(2) of the Internal Revenue Code).)
Date ____________________, 19____.
I hereby certify that I am ______________ of ______________ (State or local government) that I am authorized to execute this certificate; and that
(CHECK APPLICABLE TYPE OF CERTIFICATE)
______the liquid or liquids specified in the accompanying order, or on the reverse side hereof, (or)
______all orders placed by the purchaser for the period commencing __________ (Date) and ending __________ (Date) (period not to exceed 12 calendar quarters) are, or will be, purchased from __________ (Name of vendor) for the exclusive use of __________ (Governmental unit) of ____________________ (State or local government).
I understand that the exemption from tax in the case of sales of liquids under this exemption certificate is limited to the sale of articles purchased for the exclusive use of a State, etc. I understand that the fraudulent use of this certificate for the purpose of securing this exemption will subject me and all parties making such fraudulent use of this certificate to a fine of not more than $10,000, or to imprisonment for not more than 5 years, or both, together with costs of prosecution.
Signature ____________________
Address ____________________
26 C.F.R. §48.4041-15