Michigan Sales and Use Tax Certificate of Exemption Please fill out the form below: SECTION 1: TYPE OF PURCHASECheck one of the following: *A. One-Time PurchaseB. Blanket Certificate. Recurring Business RelationshipC. Blanket CertificateOrder or Invoice Number: *Expiration Date (maximum of four years): *The purchaser completing this form hereby claims exemption from tax on the purchase of tangible personal property or services purchased from the seller named below. This claim is based upon: the purchaser’s proposed use of the property or services; OR the purchaser’s exempt status.Seller's Full Name *SECTION 2: ITEMS COVERED BY THIS CERTIFICATECheck one of the following: *All items purchased.Limited to the following items:List Items *SECTION 3: BASIS FOR EXEMPTION CLAIMCheck one of the following:For Lease. Purchaser will lease the property and elects to pay tax based on rental receipts.For Resale at Retail.Direct PayEnter sales tax license or use tax registration number: *Enter Sales Tax License Number: *Authorized to pay use tax on qualified transactions directly to Michigan Treasury under account number: *The following exemptions DO NOT require the purchaser to provide a number:Agricultural Production.Government Entity (U.S. or its instrumentalities, State of Michigan or its political subdivisions), Nonprofit School, Nonprofit Hospital, Church or House of Religious Worship (circle type of organization)Contractor (provide Michigan Sales and Use Tax Contractor Eligibility Statement (Form 3520)).For Resale at Wholesale.Industrial Processing.Nonprofit Internal Revenue Code Section 501(c)(3), 501(c)(4), or 501(c)(19) Exempt Organization.Nonprofit Organization with an authorized letter issued by Michigan Department of Treasury prior to July 17, 1998 (sales tax) or June 13, 1994 (use tax).Rolling Stock purchased by an Interstate Motor Carrier.OtherEnter percentage: *Enter percentage: *Explain *SECTION 4: CERTIFICATIONI declare, under penalty of perjury, that the information on this certificate is true, that I have consulted the statutes, administrative rules and other sources of law applicable to my exemption, and that I have exercised reasonable care in assuring that my claim of exemption is valid under Michigan law. In the event this claim is disallowed, I accept full responsibility for the payment of tax, penalty and any accrued interest, including, if necessary, reimbursement to the vendor for tax and accrued interest.Business Name *Type of Business *Business Address *City *State/Province *ZIP / Postal code *Business Telephone Number (include area code) *Name *Title *Date Signed *Submit Signature Clear
