US & UT Certificate

Name of Firm (Buyer):

Address:

Address 1:

City: State: Zip:

Is engaged as a registered:
Wholesaler
Retailer
Manufacturer
Seller (California)
Lessor
Other

Telephone: Fax:

Email:

and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or service to be resold, leased or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:

Description of Business:

General description of tangible property or taxable services to be purchased from the seller:

Tax ID # State of Registration

I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state.

Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.

Authorized Signature:

Choose One:

Title:

Date: