UNITED STATES TAX EXEMPTIO FORMS

NSN 7540- 01-152-8080

PREVIOUS EDITION NOT USABLE

U.S. TAX EXEMPTION
FORM

Read the instructions on the reverse Side.

DEPARTMENT, AGENCY, OR OFFICE

SERIAL NO.

ITEM PURCHASED FOR EXCLUSIVE USE OF THE U.S. GOVERNMENT (Describe)

QAANITY

UNIT PRICE($)

VENDOR FORM WHICH PURCHASED

NAME

A tax exemption form has not previously been issued  and the described item(s) has (have) been delivered and invoiced pursuant to:

AMOUNT OF TAX EXCLUDED ($)

ADDRESS (No., Street, City, State, and Zip Code)

STATE

LOCAL

The Information on this form is true and correct to the best of my knowledge and belief.

P.O. OR CONTRACT NO.

FOR ADMINISTRATIVE OFFICE

PURCHASER'S
SIGNATURE,

►

DATE

DATES

D.O. SYMBOL NO:

OFFICE TITLE,
AND ADDRESS

VOUCHER NO:

SIGNATURE
AND TITLE OF
VENDOR'S
REPRESENTATIVE

►

DATE

DATE:

INSTRUCTIONS

1.  This form will be used to establish the Government's exemption or immunity for State or Local taxes whenever no other evidence is available

2.  This form shall NOT be used for:

(a)  Purchases of quarters or subsistence made by employees in travel status.

(b)  Expenses incident to use of a privately owned motor vehicle for which a mileage allowance has been authorized, or

(c)  Merchandise purchased which is subject only to Federal Tax.

3.  If the spaces provided on the face of this are inadequate, attach a separate statement containing the required information.

4.  If both State and local taxes are involved, use a separate form for each tax. The form will be provided to the vendor when the prices exclude State or local tax.

5.  The serial number of each form prepared will be shown on the payment voucher.

THE FRAUDULENT USE OF THIS FORM FOR THE PURPOSE OF OBTANINING EXCEPTION FROM OR ADJUSTMENT OF TAXES IS PROHIBITED.

STANDARD FORM 1094 (REV. 12-96
Prescribed by GSA-FAR (48 CFR) 53.229