Excise Tax Exemption Certificate - Georgia



EXCISE TAX EXEMPTION CERTIFICATE

                                                   

(Date)

The undersigned hereby certifies that

                                                                                                                                      __________  

(Print Individual's Name, Title and State Entity)

is authorized by the Department of Administrative Services, State Purchasing Division to execute this

certificate and that the article or articles specified in the accompanying order or on the reverse side

hereof, are purchased from:

                                                                                                                                 , State of Georgia.

(State Entity Name)

It is understood that the exemption form from tax in the case of sales or articles under this

exemption certificate of the United States, etc., is limited to the sale of articles purchase for their

exclusive use, and it is agreed that if the articles purchased tax free under this exemption certificate

are used otherwise or sold to employees or others, such fact must be reported to the manufacturer

of the articles covered by this certificate to secure exemption will subject the undersigned and all

guilty parties to a fine of not more than $10,000 or to imprisonment for not more than five years,

or both together with cost of prosecution. This certificate applies to purchases substantiated by

official Purchase Order issued by:

                                                                                             

(State Entity Name)

_________________________________________________

(Signature) (Title)

-----------------------

Department of Administrative Services

Statewide Business Services

State Purchasing Office

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