|
EXEMPTION CERTIFICATE
For use by State and local governments (section 422(a)(4) of the Internal Revenue Code Date ________________20____ 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 ______ 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 PARAKLESE TECHNOLOGIES LLC (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 all applicable criminal penalties under Internal Revenue Code. Signature:_______________________________ Address: _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________
Please fax to Paraklese Technologies at 812-981-7860 |