Tax Exemption Station 503.pdf

REV-1220 (TR) 07-23 (Fl) PENNSYLVANIA EXEMPTION

CERTIFICATE

•• STATE AND LOCAL SALES AND USE TAX

STATE 6% AND LOCAL 1% HOTEL OCCUPANCY TAX

PUBLIC TRANSPORTATION ASSISTANCE TAXES AND FEES (PTA)

VEHICLE RENTAL TAX (VRT)

ADDITIONAL LOCAL, CITY, COUNTY HOTEL TAX *

pennsylvania w DEPARTMENT OF REVENUE

This form cannot be used to obtain a Sales Tax License ID, PTA License ID or Exempt Status.

(Please Print or Type)

Read Instructions On Reverse Carefully

THIS FORM MAY BE PHQIREOPIED — VOID UNLESS COMPLETE INFORI, ,,,!.* , *

CHECK ONE: PENNSYLVANIA TAX UNIT EXEMPTION CERTIFICATE (USE FOR ONE TRANSACTION)

0 PENNSYLVANIA TAX BLANKET EXEMPTION CERTIFICATE (USE FOR MULTIPLE TRANSACTIONS)

Name of Seller, Vendor or Lessor

Street City State ZIP Code

NOTE: Do not use this form for claiming an exemption on the registration of a vehicle. To claim an exemption from tax for a motor vehi-cle, trailer, semi-trailer or tractor with the PA Department of Transportation, Bureau of Motor Vehicles, use one of the following forms:

FORM MV-1, Application for Certificate of Title (first-time registrations)

FORM MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration (other registrations)

Property and services purchased or leased using this certificate are exempt from tax because: (Select the appropriate paragraph from the back of this form, check the corresponding block below and insert information requested).

1. Property or services will be used directly and predominately by purchaser in performing purchaser's operation of:

• 2. Purchaser is a/an: Federal Government Agency holding Sales Tax Exemption Number 25172102

3. Property will be resold under License ID (If purchaser does not have a PA Sales Tax License ID, include a statement under Number 8 explaining why a number is not required).

4. Property or services will be used directly and predominately by purchaser performing a public utility service.

PA Public Utility Commission PUC Number and/or U.S. Department of Transportation MC/MX

5. Exempt wrapping supplies, License ID (If purchaser does not have a PA Sales Tax License ID, include a statement under Number 8 explaining why a number is not required).

, 6. Canned computer software purchased by a financial institution subject to the Bank and Trust Company Shares Tax (Article VII) or the Mutual Thrift Institutions Tax (Article XV).

, 7. Canned computer software licenses that are billed to a PA address but used outside of PA. The total number of software licenses purchased for invoice # is The total number of users accessing and using the software outside PA is

8. Other (Explain in detail. Additional space on reverse side).

I am authorized to execute this certificate and claim this exemption. Misuse of this certificate by seller, lessor, buyer, lessee or their representative is punishable by fine and imprisonment.

Name of Purchaser or Lessee

James E. Van Zandt VA Medical Center

SiMr D _ EIN

25172102

Date

09/27/2023

Street

Pleasant Valley Blvd

City

Altoona

State

PA

ZIP Code

16602

I. ACCEPTANCE AND VALIDITY:

For this certificate to be valid, the seller/lessor shall exercise good faith in accepting this certificate, which includes: (1) the certificate shall be completed properly; (2) the certificate shall be in the seller/lessor's possession within 60 days from the date of sale/lease; (3) the certificate does not contain infor-mation which is knowingly false; and (4) the property or service is consistent with the exemption to which the customer is entitled. For more information, refer to Exemption Certificates, Title 61 PA Code §32.2. An invalid certificate may subject the seller/lessor to the tax.

2. REPRODUCTION OF FORM:

This form may be reproduced but shall contain the same information as appears on this form.

3. RETENTION:

The seller or lessor must retain this certificate for at least four years from the date of the exempt sale to which the certificate applies.

A IMPORTANT: DO NOT RETURN THIS FORM TO THE PA DEPARTMENT OF REVENUE.

4. NONPROFIT EXEMPT ORGANIZATIONS:

This form may be used in conjunction with form REV-1715, Exempt Organization Declaration of Sales Tax Exemption, when a purchase of $200 or more is made by an organization which is registered with the PA Department of Revenue as an exempt organization. These organizations are assigned an exemption number, beginning with the two digits 75 (example: 75000000).