REV1220 A5+ (2.93)

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF REVENUE

BUREAU OF BUSINESS TRUST FUND TAXES

DEPT 280901

HARRISBURG, PA 17128-0901	PENNSYLVANIA

EXEMPTION CERTIFICATE

CHECK ONE:

STATE OR LOCAL SALES AND USE TAX

STATE OR LOCAL HOTEL OCCUPANCY TAX

PUBLIC TRANSPORTATION ASSISTANCE TAXES AND FEES (PTA)

(Please Print or Type)

This Form cannot be used to obtain

a Sales Tax License Number, PTA

License Number, or Exempt Status

Read Instructions

On Reverse Carefully
THIS FORM MAY BE PHOTOCOPIED – VOID UNLESS COMPLETE INFORMATION IS SUPPLIED
CHECK ONE:	PENNSYLVANIA TAX UNIT EXEMPTION CERTIFICATE (USE FOR ONE TRANSACTION)
PENNSYLVANIA TAX BLANKET EXEMPTION CERTIFICATE (USE FOR MULTIPLE TRANSACTIONS)
Name of Seller Or Lessor
Street	City	State	ZIP Code

Property and services purchased or leased using this certificate are exempt from tax because:

(Select the appropriate paragraph from the back of this form, check the corresponding block below, and insert information requested)
1.	Property or services will be used directly by purchaser in performing purchaser’s operation of:
.
2.	Purchaser is a/an:
3.	Property will be resold under License Number
. (If purchaser does not have a PA Sales
Tax License Number, include a statement under Number 7 explaining why a number is not required.
4.	Purchaser is a/an
holding Exemption Number
5.	Property or services will be used directly by purchaser performing a public utility service. (Complete Part 5 on Reverse)
6.	Exempt wrapping supplies, License Number _____________________ . (If purchaser does not have a PA Sales Tax License
Number, include a statement under Number 7 explaining why a number is not required.)
7.	Other	Commonwealth of Pennsylvania Fed ID #
(Explain in detail. Additional space on reverse side.) Card #
I am authorized to execute this Certificate and claim this exemption. Misuse of this Certificate by seller, lessor, buyer, lessee, or their

representative is punishable by fine and imprisonment.
Name of Purchaser or Lessee	Signature	Date
Street Address	City	State	ZIP Code
1.	ACCEPTANCE AND VALIDITY:
For this certificate to be valid, the seller/lessor shall exercise good faith in accepting this certificate, which includes: (1) the certificate shall be completed properly; (2) the certificate shall be in the seller/lessor’s possession within sixty days from the date of sale/lease; (3) the certificate does not contain information which is knowingly false; and (4) the property or service is consistent with the exemption to which the customer is entitled. For more information, refer to Regulation 200, Exemption Certificates (Title 61 PA Code §32.2). An invalid certificate may subject the seller/lessor to the tax.
2.	REPRODUCTION OF FORM:
This form may be reproduced but shall contain the same information as appears on this form.
3.	RETENTION:
The seller or lessor must retain this certificate for at least four years from the date of the exempt sale to which the certificate applies. DO NOT RETURN THIS FORM TO THE PA DEPARTMENT OF REVENUE.
4.	EXEMPT ORGANIZATIONS
This form may be used in conjunction with form REV-1715, Exempt Organization Declaration of Sales Tax Exemption, when a purchase of $200 or more is made by an organization which is registered with the PA Department of Revenue as an exempt organization. These organizations are assigned an exemption number, beginning with the two digits 75 (example 75-00000-0).

Enclosure 3 to Management Directive 230.13

Pennsylvania Exemption Certificate and Completion Instructions

Under the center heading, place an ‘X’ in block State or Local Hotel Occupancy Tax and cross out the State or on the heading.

Place an “X” in block Pennsylvania Tax Blanket Exemption Certificate. (Use for Multiple Transactions)

Place an “X” in block 7. Other and enter Commonwealth of Pennsylvania FED ID#. (This is the Department Number available from agency coordinator.)

On second line of block 7. (Explain in detail. Additional space on reverse side.) Enter employe’s Corporate Card Number.

Complete authorization section: employe name, signature, date, street address, city, state, and zip code.

Note: This form may be duplicated and presented to hotels on request. Be sure to complete for each hotel the vendor section: name of seller or lessor, street address, city, state, and zip code.

PENNSYLVANIA

dhollera

2003-10-20

cstorm

Commonwealth of Pa