Tax Exemption Form Business Name* Contact Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Enter Email Confirm Email Account # Employer ID # 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:* Yes No Section 1: Exemption is for:* One Time Purchase Blanket Certificate* (Recurring Business Relationship) Blanket Certificate* (maximum of 4 years) Section 2: Items covered by this certificate:* All Items Purchased Limited to the items listed below Exemption limited to the following items:Section 3: Basis for exemption claim:*ResaleAgricultural ProductionIndustrial ProcessingNon-Profit OrganizationOtherSection 4: CertificationIn 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: Yes No Expiration date (if less than three years):* A blanket certificate is valid for three years from the date of filling out this form unless an earlier expiration date is stipulated below. Untitled First Choice Second Choice Third Choice
