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The purchaser hereby claims exemption on the purchase of tangible personal property and selected services made under this certificate from the Ellsworth Farmers Exchange. This certificate is invalid unless all four sections have been completed by the purchaser.

I understand and agree to this statement:

Section 1: Exemption is for:

 Section 2: Items covered by this certificate:

Exemption limited to the following items:

Section 3: Basis for exemption claim:

Section 4: Certification:

In the event this claim is disallowed, the purchaser promises to reimburse the seller for the amount of the tax involved.

I understand and agree with this statement:

Expiration date (if less than three years: