Fillable Form Rev-1220 (As+) - Pennsylvania Exemption Certificate

PENNSYLVANIA EXEMPTION

reV-1220 (as+) 05-17

CERTIFICATE

This form cannot be used to

obtain a Sales Tax Account

START

ID, PTA Account ID or Exempt

state and LoCaL saLes and use tax

Status.

state 6% and LoCaL 1% hoteL oCCuPanCY tax

(Please Print or Type)

PubLiC transPortation assistanCe taxes and fees (Pta)

bureau of

Read Instructions

business trust fund taxes

VehiCLe rentaL tax (Vrt)

On Reverse Carefully

Po box 280901

harrisburg Pa 17128-0901

ADDITIONAL LOCAL, CITY, COUNTY HOTEL TAX

THIS FORM MAY BE PHOTOCOPIED – VOID UNLESS COMPLETE INFORMATION IS SUPPLIED

CHECK ONE:

PENNSYLVANIA TAX UNIT EXEMPTION CERTIFICATE (USE FOR ONE TRANSACTION)

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 vehicle, 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:

3. Property will be resold under Account ID____________________________ . (If purchaser does not have a PA Sales Tax Account ID, include

a statement under Number 7 explaining why a number is not required.)

4. Purchaser is a/an: ______________________________________________________ holding Exemption Account ID

5. 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

6. Exempt wrapping supplies, Account ID____________________________ . (If purchaser does not have a PA Sales Tax Account ID, include

a statement under Number 7 explaining why a number is not required.)

7. 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

Signature

EIN

Date

Please sign after printing.

Street

City

State

ZIP Code

1. 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 information

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.

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

4. 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: 75-00000-0).

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