36E77619R0028-0002002.pdf

Name of purchaser

Business address City State Zip code

Purchaser’s tax ID number State of issue

If no tax ID number, FEIN Driver’s license number/State issued ID number enter one of the following: state of issue number

Name of seller from whom you are purchasing, leasing or renting

Seller’s address City State Zip code

Type of business. Circle the number that describes your business.

Reason for exemption. Circle the letter that identi es the reason for the exemption.

01 Accommodation and food services 0 Agricultural, forestry, shing, hunting 03 Construction 04 Finance and insurance 05 Information, publishing and communications 06 Manufacturing 07 Mining 08 Real estate 09 Rental and leasing 10 Retail trade

11 Transportation and warehousing 12 Utilities 13 Wholesale trade 14 Business services 15 Professional services 16 Education and health-care services 17 Nonpro t organi ation 18 Government 19 Not a business (explain) 20 Other (explain)

Ty pe o r pr in t Ty pe o f b us in es s R ea so n fo r ex em pt io n

Signature of authori ed purchaser Print name here Title Date

Si gn h er e erti ate of xemption

This is a blan et certi cate, unless one of the boxes below is chec ed, and remains in force as long as the purchaser continues ma ing purchases, or until otherwise cancelled by the purchaser.

Chec if this certi cate is for a single purchase and enter the related invoice/purchase order .

If you are a contractor and have a purchasing agent agreement with an exempt organi ation, chec the box to ma e multiple purchases for a speci c ob. Enter the exempt entity name and speci c pro ect:

Exempt entity name Pro ect description

A Federal government (department)

B Speci c government exemption (from list on back)

C Tribal government (name)

D Foreign diplomat E Charitable organi ation F Educational organi ation G Religious organi ation H Resale

I Agricultural production J Industrial production/manufacturing

Direct pay authori ation L Multiple points of use (services, digital goods, or computer software delivered electronically)

M Direct mail N Other (enter number from back page)

O Percentage exemption Advertising (enter percentage) %

Utilities (enter percentage) %

Electricity (enter percentage) % ur haser Complete this certi cate and give it to the seller.

Seller If this certi cate is not fully completed, you must charge sales tax. eep this certi cate as part of your records.

ST3

Rev. 6/14 Forms and fact sheets are available on our website at www.revenue.state.mn.us

US Department of Veterans Affairs - Minneapolis VA Health Care System

1 Veterans Drive Minneapolis MN 55417

41-0696270 Minnesota

Dept of Veterans Affairs