DNT Texas Sales and Use Tax Exemption Certification

01-339 (Back)
(Rev.4-138))

This certificate does not require a number to be valid.

Name of purchaser, firm or agency

Address (Street & number, P.O. Box or Route number)

Phone (Area code and number)

Format: (000) 000-0000.

City, State, ZIP code

I, the purchaser named above, claim an exemption from payment of sales and use taxes (for the purchase of taxable items described below or on the attached order or invoice) from:

Seller: Chick fil A Dallas North Tollway and West Frontier Parkway

Street address: 1920 North Dallas Parkway

City, State, ZIP code: Prosper, TX, 75078

Description of items to be purchased or on the attached order or invoice:

Purchaser claims this exemption for the following reason:

I understand that I will be liable for payment of all state and local sales or use taxes which may become due for failure to comply with the provisions of the Tax Code and/or all applicable law.
I understand that it is a criminal offense to give an exemption certificate to the seller for taxable items that I know, at the time of purchase, will be used in a manner other than that expressed in this certificate, and depending on the amount of tax evaded, the offense may range from a Class C misdemeanor to a felony of the second degree.

Purchaser Signature

Title

Date

NOTE: This certificate cannot be issued for the purchase, lease, or rental of a motor vehicle.
THIS CERTIFICATE DOES NOT REQUIRE A NUMBER TO BE VALID.
Sales and Use Tax "Exemption Numbers" or "Tax Exempt" Numbers do not exist.

This certificate should be furnished to the supplier.
Do not send the completed certificate to the Comptroller of Public Accounts.