Exemption Certificate
(For use by States and local governments (section 4221(a)(4) of the Internal Revenue Code))
(Date) __________________________, 19____.
I hereby certify that I am __________________ (Title of Officer) of __________________ (State or local government) that I am authorized to execute this certificate; and that:
(Check applicable type of certificate)
____ the article or articles 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 manufacturer) 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 articles under this exemption certificate to a State, etc., is limited to the sale of articles purchased for its exclusive use. 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. §48.4221-5