Exemption Number Name of Exempt Institution
Important—Certifi cate not
valid unless completed.
PURCHASE EXEMPTION
CERTIFICATE
Check Applicable Block
Blanket
Single Purchase
I hereby certify that ___________________________________ is a Kentucky resident, nonprofi t educational, charitable or
religious institution, or Kentucky historical site, located at ___________________________, Kentucky and that the tangible
personal property, digital property or services to be purchased from
_____________________________________________
_____________________________________________________________________________________________________________
will be used solely within the exempt function of a charitable, educational or religious institution, or historical site.
Description of property to be purchased:
____________________________________________________________________
_____________________________________________________________________________________________________________
In the event that the property purchased is not used for an exempt purpose, it is understood that I am required to
pay the tax measured by the purchase price of the property.
Any offi cial or employee who uses this certifi cate to make tax-free purchases for his own personal use or that of
any other person will be subject to the penalties provided in KRS 139.990 and other applicable laws.
Under penalties of perjury, I swear or affi rm that the information on this certifi cate is true and correct as to every
material matter.
Name of Exempt Institution
Name of Vendor
Address
CAUTION TO SELLER: This certifi cate cannot be issued or used
in any way by a construction contractor to purchase property
to be used in fulfi lling a contract with an exempt institution.
Sellers accepting certifi cates for such purchases will be held
liable for the sales or use tax.
Authorized Signature Title
Date
DEPARTMENT OF REVENUE
Frankfort, Kentucky 40620
51A126 (12-09)
