1022 TAX EXEMPTION FORM

Name of Seller, Vendor or Lessor
Street
City
State ZIP Code
HOW WOULD YOU DESCRIBE YOUR BUSINESS ?
PENNSYLVANIA EXEMPTION CERTIFICATE
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
Should be Empty: