DEPARTMENT OF THE TREASURY
BUREAU OF ALCOHOL, TOBACCO AND FIREARMS
(For use by state and local governments (Section 4221 (a) (4) of the Internal Revenue Code).)
(DATE) ____________________________20 ____.
I hereby certify that I am ___________________(Title of Officer) of __________________________,
that I am authorized to execute this certificate, and that (check applicable type of certificate):
c The article or articles specified in the accompanying order or on the reverse side hereof,(or)
c All orders placed by the purchaser for the period commencing __________, 20 _____
and ending _______________, 20 _____ (Period not to exceed 12 calendar quarters),
(Name of Manufacturer)
exclusive use of ________________________ of _____________________________
(Government unit) (State of local government).
I understand that the exemption from tax in the case of sales of articles under this exemption
certificate to a state, etc., is limited to the sale of articles purchased for its exclusive use*. I
understand that fraudulent use of this certificate for the purpose of securing this exemption will
subject me and all parties making such fraudulent use of this certificate to all applicable
criminal penalties under the Internal Revenue Code.
All blanks must be filled in for this certificate to be valid for the 3 year
period. If any (except signature) are left blank, it will be filled in and
handled as a certificate for that specific order only! There MUST be a
signature on each form.
*A sale of an article to a State or local government for resale is not considered to be a sale for the “exclusive use” of the State or local
government, within the meaning of section 4221 (a)(4) of the code, and , therefore, such sales may not be made tax-free. Such sales
may not be made tax-free even if the resales are made to government employees, or the article is an item of equipment the employee is
required to possess in carrying out his duties.