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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