Texas Sales & Use Tax Exemption Certificate

Name of purchaser, firm or agency

Address (Street & number, P.O. Box or Route number)

Phone (Area code and number)

City, State, ZIP code

I, the purchaser named above, claim an exemption from payment of sales and use taxes for the purchase of taxable
items described below or on the attached order or invoice form

Seller:

Street address:

City, State, ZIP code:

Description of items to be purchased or on the attached order or invoice:

Purchaser claims this exemption for the following reason:

I understand that I will be liable for payment of sales or use taxes which may become due for failure to comply with the provisions of the
Tax Code: Limited Sales, Excise, and Use Tax Act; Municipal Sales and Use Tax Act; Sales and Use Taxes for Special Purpose Taxing
Authorities; County Sales and Use Tax Act; County Health Services Sales and Use Tax; The Texas Health and Safety Code; Special
Provisions Relating to Hospital Districts, Emergency Services Districts, and Emergency Services Districts in counties with a population
of 125,000 or less.
I understand that it is a criminal offense to give an exemption certificate to the seller for taxable items that I know, at the time of purchase,
will be used in a manner other than that expressed in this certificate and, depending on the amount of tax evaded, the offense may range
from a Class C misdemeanor to a felony of the second degree.

Purchaser

Title

Date

NOTE: This certificate cannot be issued for the purchase, lease, or rental of a motor vehicle.
THIS CERTIFICATE DOES NOT REQUIRE A NUMBER TO BE VALID.
Sales and Use Tax "Exemption Numbers" or "Tax Exempt" Numbers do not exist.

This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts.