Uniform Sales & Use Tax Certificate

Multi-State

Issued to (Seller):

McPhersons

957 North Meridian Street

Sunman, IN  47041

I certify that:

Account #

is engaged as a registered

Wholesaler

Retailer

Manufacturer

Other (Specify)

and is registered with the below listed states within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product to be resold, leased, or rented in the normal course of our business.  We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following:

Description of business

State

State

ID#

ID#

I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax, we will pay the tax due direct to the proper taxing authority when state law so provides.  This certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the state.

General description of products to be purchased from the Seller:

Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter.

Authorized Signature:  ____________________________________________________________

Title

Date:

This form is invalid without a signature and date.