Iowa Sales Tax Exemption Certificate | Fort Dodge Transmission

Certificate Type *

Single Purchase

This certificate applies to one specific purchase transaction.

Blanket Certificate

Valid until revoked, or until 12 months have elapsed with no purchases between the same seller and purchaser.

1 — Purchaser Information

Purchaser Legal Name *

Doing Business As (DBA) (if different)

Street Address *

City *

State *

ZIP *

Phone *

Email *

Identification Number Type * (most purchasers use their Iowa sales/use tax permit number)

2 — Purchaser Business Type *

3 — Reason for Exemption *

4 — Seller Information

Fort Dodge Transmission

3553 5th Ave S, Fort Dodge, IA 50501

5 — Certification & Signature

I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this certificate, and, to the best of my knowledge and belief, it is true, correct, and complete. I declare that I am authorized to act on behalf of the taxpayer, and will act only within my authority.

Printed Name *

Title / Position *

Date *

Signature * — draw using mouse or touch

Sign here using your mouse or finger