2.2.1_Base IDIQ Attachment 1_SF1094-15c Tax Exemption Form.pdf
PDF 1 MB Posted
- Attached to
- DHS FEMA Permanent Housing Construction (PHC) – Repairs Federal contract opportunity
- Solicitation number
- 70FBR825R00000002
- Issued by
- Federal Emergency Management Agency
About this file
The document is a United States Tax Exemption Form (Standard Form 1094, Rev. 4/2015) used to establish the government's exemption or immunity from State or Local taxes when no other evidence is available. The form provides instructions for its use, specifically noting it should not be used for employee travel expenses, mileage allowances, or merchandise subject only to Federal Tax. Key instructions include using separate forms for State and Local taxes, attaching additional statements if space is inadequate, and warning that fraudulent use to obtain tax exceptions is prohibited. The form is designed to be completed by a government purchaser and vendor when acquiring items for exclusive government use, requiring details such as vendor information, purchase/contract number, quantity, unit price, and tax exclusion amounts.
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Text version
UNITED STATES
TAX EXEMPTION FORM
VENDOR FROM WHICH PURCHASED
The information on this form is true and correct to the best of my knowledge and belief.
A tax exemption form has not previously been issued and the described item(s) has (have) been delivered and invoiced pursuant to:
Read the instructions on the reverse side.
NAME
PURCHASE OR
CONTRACT NUMBER
PURCHASER'S OFFICE TITLE
TITLE OF VENDOR'S REPRESENTATIVE
PREVIOUS EDITION NOT USABLE
ADDRESS (Number, Street, City, State, and ZIP Code)
PURCHASER'S ADDRESS
ITEM PURCHASED FOR EXCLUSIVE USE OF THE UNITED STATES GOVERNMENT (Describe)
SERIAL NUMBER
QUANTITY
AMOUNT OF TAX EXCLUDED ($)
FOR ADMINISTRATIVE OFFICE
DESIGNATED OFFICE SYMBOL NUMBER
VOUCHER NUMBER
STATE
LOCAL
DATES
DATE:
DATE:
DATE:
UNIT PRICE ($)
DEPARTMENT, AGENCY, OR OFFICE
STANDARD FORM 1094 (REV. 4/2015)
Prescribed by GSA-FAR (48 CFR) 53.229
SIGNATURE OF VENDOR'S REPRESENTATIVE
PURCHASER'S SIGNATURE
INSTRUCTIONS
1. This form will be used to establish the Government's exemption or immunity from State or Local taxes whenever no other evidence is available.
2. This form shall NOT be used for:
(a) Purchase of quarters or subsistence made by employees in travel status.
(b) Expenses incident to use of a privately owned motor vehicle for which a mileage allowance has been authorized, or
(c) Merchandise purchased which is subject only to Federal Tax.
3. If the spaces provided on the face of this form are inadequate, attach a separate statement containing the required information.
4. If both State and Local taxes are involved, use a separate form for each tax. The form will be provided to the vendor when the prices exclude State or Local tax.
5. The serial number of each form prepared will be shown on the payment voucher.
THE FRADULENT USE OF THIS FORM FOR THE PURPOSE OF OBTAINING
EXCEPTION FROM OR ADJUSTMENT OF TAXES IS PROHIBITED.
STANDARD FORM 1094 (REV. 4/2015) BACK
UNITED STATES TAX EXEMPTION FORM
VENDOR FROM WHICH PURCHASED
The information on this form is true and correct to the best of my knowledge and belief.
A tax exemption form has not previously been issued and the described item(s) has (have) been delivered and invoiced pursuant to:
Read the instructions on the reverse side.
NAME
PURCHASE OR CONTRACT NUMBER
PURCHASER'S OFFICE TITLE
TITLE OF VENDOR'S REPRESENTATIVE
PREVIOUS EDITION NOT USABLE
ADDRESS (Number, Street, City, State, and ZIP Code)
PURCHASER'S ADDRESS
ITEM PURCHASED FOR EXCLUSIVE USE OF THE UNITED STATES GOVERNMENT (Describe)
SERIAL NUMBER
QUANTITY
AMOUNT OF TAX EXCLUDED ($)
FOR ADMINISTRATIVE OFFICE
DESIGNATED OFFICE SYMBOL NUMBER
VOUCHER NUMBER
STATE
LOCAL
DATES
UNIT PRICE ($)
DEPARTMENT, AGENCY, OR OFFICE
STANDARD FORM 1094 (REV. 4/2015)
Prescribed by GSA-FAR (48 CFR) 53.229
INSTRUCTIONS
1. This form will be used to establish the Government's exemption or immunity from State or Local taxes whenever no other evidence is available.
2. This form shall NOT be used for: (a) Purchase of quarters or subsistence made by employees in travel status. (b) Expenses incident to use of a privately owned motor vehicle for which a mileage allowance has been authorized, or (c) Merchandise purchased which is subject only to Federal Tax.
3. If the spaces provided on the face of this form are inadequate, attach a separate statement containing the required information.
4. If both State and Local taxes are involved, use a separate form for each tax. The form will be provided to the vendor when the prices exclude State or Local tax.
5. The serial number of each form prepared will be shown on the payment voucher.
THE FRADULENT USE OF THIS FORM FOR THE PURPOSE OF OBTAINING EXCEPTION FROM OR ADJUSTMENT OF TAXES IS PROHIBITED.
STANDARD FORM 1094 (REV. 4/2015) BACK
11.0.0.20130303.1.892433.887364
| Voucher Number: |
| Amount excluded from Local Taxes: |
| Voucher Date: |
| Purchaser's Signature Date: |
| Vendor's Representative Signature Date: |
| Amount excluded from State Taxes: |
| Unit Price: |
| SignatureField1: |
| Purchaser's Address: |
File details come from the government source that posted it. Updated .