Texas Sales and Use Tax Exemption Certification *Name of Purchaser, Firm or Agency: *Account Number: *Address: *City: *State: *ZIP Code: *Phone Number: *Email Address: I, the purchaser named above, claim an exemption from payment of sales and use taxes for the purchase of taxable items described below or on the attached order or invoice: Seller Information: MEDINA ELECTRIC COOPERATIVE, INC. PO BOX 370 HONDO, TX 78861-0370 Description of items to be purchased: Electricity PLEASE COMPLETE ONLY ONE SECTION A, B, OR C (AS APPLICABLE) Select Section B for Apartment Complexes or Cotton Gins. Select Section A for 100% Nontaxable Usage. (Utility Study not Required) Select Section C if electricity used is less than 100%, but more than 50% (Utility Study REQUIRED). Select applicable Section: Section A Section B Section C Section A. Utility Study not required for 100% Nontaxable Usage Check only ONE: Purchaser claims this exemption for the following tax exempt reason: Electricity is used 100% in exploring for, producing or transporting a material extracted from the earth. Texas Direct Permit Number Permit Number (11-digit): Purchase by Exempt Organization that has obtained a Texas Comptroller letter of exempt status under IRC Code Section. Specify Type of Code Section. Type or Code Section: Other (specify Texas Tax Code Section and use of electricity): Other use and Tax Code Section: Section B. Utility Study not required - Only for Use by Apartment Complexes or Cotton Gins Customer declares electricity is used less than 100%, but more than 50% for residential purpose in an apartment complex. Customer declares electricity is used less than 100%, but more than 50% for processing in a Cotton Gin. Section C. Predominant Use Exemption Customer declares electricity is used less than 100%, but more than 50%, for a tax exempt purpose and affirms that a valid and complete study has been performed which shows that the percentage of electricity listed below is used for the following tax exempt purpose: (check only one) Percentage used: Manufacturing, processing or fabricating tangible personal property for sale in the regular course of business. Other tax exempt use (specify exact use): Other use: Click here to draw your signature. Owner's (Customer's) Signature With your mouse, draw your signature. Then click Finish. Date Signed: (MM/DD/YYYY) I understand that I will be liable for payment of all state and local sales or use taxes which may become due for failure to comply with the provisions of the Tax Code and/or all applicable law. I understand that it is a criminal offense to give an exemption certificate to the seller for taxable items that I know, at the time of purchase, will be used in a manner other than that expressed in this certificate and, depending on the amount of tax evaded, the offense may range from a Class C misdemeanor to a felony of the second degree. Click here to draw your signature. Authorized signature With your mouse, draw your signature. Then click Finish. Name: Official Title: Date Signed: (MM/DD/YYYY)
