Kentucky Sales Tax Out-of-State Purchase Exemption Certificate

Sales Tax Out-of-State Purchase Exemption Certificate
51A127 (12-09).indd
Important—Not valid
unless completed.

OUT–OF–STATE PURCHASE
EXEMPTION CERTIFICATE

Check Applicable Block
Blanket
†
Single Purchase
†

I hereby certify that _______________________________________________________________________________
Name of Agency or Institution

__________________________________________________________________________________________________
Address

is an out–of–state agency, organization or institution exempt in its state of residence from sales and use tax and that the tangible
personal property, digital property, or services to be purchased from:
__________________________________________________________________________________________________
Name of Vendor

__________________________________________________________________________________________________
Address
will be used solely for the exempt purpose.
Description of property or services to be purchased: _____________________________________________________
__________________________________________________________________________________________________
In the event that the property or services purchased are not used for the exempt purpose, it is understood that I am required
to pay the tax measured by the purchase price.
It is also understood that the information contained herein can be provided to the state of residence. Under penalties of
perjury, I swear or affirm that the information on this certificate is true and correct as to every material matter.
___________________________________________________

__________________________________________

Authorized Signature

___________________________________________________

Title

__________________________________________

Exemption or ID Number
CAUTION TO SELLER: This certificate can be used only for sales to agencies, organizations or
institutions which, as an entity, are exempt from sales and use taxes in their state of residence. It cannot
be used to claim exemption for specific types of property which may be exempt in the purchaser’s state
of residence. Sellers may not accept this certificate in lieu of a Resale Certificate, Multijurisdictional
Certificate or Direct Pay Authorization.

Date

51A127 (12-09)
DEPARTMENT OF REVENUE
Frankfort, Kentucky 40620