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Fortnt ST 105 Indiana Department of Revenue State Fom 49065 11418.05 General Sales 'nx Exetapiion Certificate Indiana registered retail merchants and businesses Iocated 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 Utilities. Pe t, W t teat t, orAli-craft, Purchaser must he registered with (lie Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unlessall information in each section is fully completed by the purchaser. Purchasers not able to provide all required information trust pay the, tax and may file a claim for refund (.Form OA-1 I0L) directly with the Department of Revenue. Name of Purchaser Greater St. John Missionary Baptist Church Business Address 101 N. Adams St. city South Bend State in Zip 46628 0 r. Purchaser must provide minimum of one ID number below.31 .M 04 Provide your Indiana Registered Retail Merchant's Certificate 0001947850 000 A TfD and LOC Number as shown on your Certificate ..... .......................... ._-__—. _.. T TID11(10 digits) LOC# { 3 digits) if not registered with the Indiana DOR, provide your State Tax Go IDNumber from another State................................................................ ,See instructions on the reverse side if you do not have either number. State JD# State of Issue N o Is this a ® blanket purchase exemption request or a 13single purchase exemption request? (check one) tf#. Description of items to be purchased. Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain) Sales to it retailer, wholesaler, or manufacturer for resole only. E3 Sale of manufacturing machinery, tools, and equipment to be used directly in direct production. ® Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin 410. (May not be used for personal hotel rooms and meals.) C3 Sales'of tangible personal property predomlnately used (greater then 50 percent) in providing public transportation - provide USDOT#. M A person or corporation who is hauling under someone else's motor carrier authority, or has a contract as a school bus operator, trust provide their SS# or FiD# in lieu of a State ID# in Section M. USDOT# r43 M Sales to persons, occupationally engaged as farmers, to be used directly in production of agricultural products for sale. Notes A fanner not possessing a State Business License# may enter a FID# or a SS# in lieu of a State ID# in Section # 1. 0 Sales to it contractor for exempt projects (such as public schools, government, or nonprofits). ® Sales to Indiana Goverrttilental Units (agencies, cities, towns,, municipalities, public schools, and state universities). ® Sales to tite United States %ederal Governmeut - show agency name. Note: A U.S. Government agency should enter its Federal Identification Number (FID#) in Section # 1 in lieu of a State ID#. 2) other- explain. Use by Non -Profit 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. VI confirm my understanding that misuse, (ehherneglibyeul or intentional), and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the 1111position of tax, interest, and civil and/or criminal penalties. cri Signature orPurebaser /.4 -LA Yf<` Date f Printed Name Kertnsth Byrd Sr. Title Treasurer I lie Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller luust keep this certificate on file to support exempt safes.