State Form 49065 R4/ 8-05
Indiana Department of Revenue
General Sales Tax Exemption Certificate
Indiana registered retail merchants and businesses located outside Indiana may use this certificate. The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for purchases from Indiana vendors. This exemption certificate can not be issued for the purchase of Utilifia,1·, Vul1icte.1·, "ptcrcraO, or Aircra ft. Purchaser must be registered wi th the Department of Revenue or the appropriate taxi ng authori ty or the purchaser's stale or residence.
Sales tax must be charged unless all information in each section is fully completed by the purchaser. Purchasers not able to provide all required information must pay the tax and may file a claim for refund (Form GA-11 OL) directly with the Department of Revenue.
Name of Purchaser
Northwestern Indiana Regional Planning Commission
Business Address 6100 Southport Road
Purchaser must provide mi ni mu m of one TD number below.*
City Portage State IN--- Zip 46368
--S Provide your Indiana Registered Retail Merchant's Certificate
TID and LOC Number as shown on your Certificate ...............................
H not registered with Lhe Indiana DOR, provide you r Stale Tax
TTD# (I0 digits) LUC# ( 3 digils)
TD Number from another State................................................................ ---------------
*See instructions on the reverse side if you do not have either number.
State ID# State of Issue
IJlIs this a CJtb!anket purchase exemption request or a
Dsingle purchase exemption request? (check one)
l!JDescri ption or items lo he pu rchased. ---------------------------------------- Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)
D Sales to a retailer, wholesaler, or manufacturer for resale only.
Cl Sale of manufacturing machinery, tools, and equipment to be used directly in direct production .
CJ Sales to nonprofit organizations claimi ng exemption pursuant Lo Sales Tax Information Bulleti n #I 0. (May not be used for personal hotel rooms and meals.)
D Sales of tangible personal property predominately used (greater then 50 percent) in providing public transportation - provide USDOT#.
A person or corporation who is hauling under someone else's motor carrier authority, or has a contract as a school bus operator, must
J provide thei r SS# or FID# in lieu or a Stale ID# in Section #1 . USDOT# ---------
[I) CJ Sales to persons, occupationally engaged as farmers, to be used directly in production of agricultural products for sale. Note: A farmer not possessing a State Business License# may enter a FID# or a SS# in lieu of a State ID# in Section #1 .
Cl Sales to a contractor for exempt projects (such as public schools. government, or nonprofits) .
CZI Sales to Indiana Governmental Units (agencies, cities, towns, municipalities, public schools, and state universities).
Cl Sales to the United States Federal Government - show agency name. Note: A U.S. Government agency should enter its Federal Identification Number (FID#) i n Section #I in lieu of a State TD#.
CJ Other - explain .
I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5, and the item purchased is not a utility, vehicle, watercraft, or aircraft.
g l confirm my understanding that misuse, ( either nt1gligt1nl or intentional), and/or fraudulent use of this certificate may subject both me personally
and/or the business entity ep( en1 to the imposition of tax, interest, and civil and/or criminal penalties.
tn Signatu re of Pur hascr Date _1'-/'1- '1-/_2_0c..1_7_ _
Printed Namt: Angi e Hayes Title Dir. of Fin. & Admin
The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser.
Seller must keep this certificate on file to support exempt sales.