Sales and Use Tax Exemption Certificate

Sales and Use Tax Exemption Certificate
Name*
Missouri Tax I.D. Number
Contact Person*
Doing Business As Name DBA*
SSN/FEIN*
Telephone Number ()*
SS#FEIN
Address*

Address

Street Address Line 2

CityState

ZIP Code
Describe product or services purchased exempt from tax*
Produce, eggs, beverage, vinegar, cheese
Type of business*
Describe product or services purchased exempt from tax
Type of business

Seller
Name
Doing Business As Name (DBA)
Contact Person
Telephone Number

Area CodePhone Number
Number
Address

Address

Street Address Line 2

CityState

ZIP Code

(Missouri Retailers must have a Missouri Tax I.D. Number)*

Purchases of Tangible Personal Property for resale:
Retailer’s State Tax ID Number*
Home State*
Other*

AgriculturalIngredient or component

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature*

Clear
Title*
Date*

MonthDayYear
Date
Signature
Should be Empty: