1022 TAX EXEMPTION FORM

Name of Seller, Vendor or Lessor
Street
City
State ZIP Code
HOW WOULD YOU DESCRIBE YOUR BUSINESS ?*

1.MECHANIC/REPAIR SHOP/ROADSIDE ASSISTANCE2.RETAIL/RESALE/WHOLSALE( YOU MUST HAVE SALES TAX EXEMPTION NUMBER)3.CARRIER(OWNER OF DOT # AND OWNER OF THE BUSINESS ENTITY )
PENNSYLVANIA EXEMPTION CERTIFICATE

STATE AND LOCAL SALES AND USE TAX
CHECK ONE: PENNSYLVANIA TAX UNIT EXEMPTION CERTIFICATE (USE FOR ONE TRANSACTION)PENNSYLVANIA TAX BLANKET EXEMPTION CERTIFICATE (USE FOR MULTIPLE TRANSACTIONS)
1.Purchaser is MECHANIC/REPAIR SHOP/ROADSIDE ASSISTANCE *
add to field one of these above :
1.Sales Tax Exemption Number*
2.Purchaser is RETAIL/RESALE/WHOLSALE Corportion And Property Will Be Resold Under Account ID*
3. U.S. Department of Transportation MC #*
Certificate Of Organization( PA CORPORATION) or Certificate Of MC Authority(FMCSA)*

Cancelof
SS-4 Form From IRS (EIN NUMBER )*

Cancelof
UPLOAD ID / DL / CDL OF COMPANY EXECUTIVE(Owner) *

Cancelof
MC or DOT Certificate*

Cancelof
Sales Tax Exemption Certificate

Cancelof
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.
COMPANY NAME*
Name of Purchaser or Lessee*
EIN*
Date*

MonthDayYear
Date
Street*
City*
State*
ZIP Code*
PHONE NUMBER*
Email Address*
Signature*

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