A21_Tax_Exemption_Form_0001.pdf

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