ATK
CERTIFICATE OF ULTIMATE PURCHASER
The undersigned hereby certifies that they are _________________ (title of officer) and that they are authorized to execute this certificate and that the article, or articles specified below are purchased from:
Gulf States
Distributors
for the exclusive use by:__________________________________________
6000 E
Shirley Lane
agency name
Montgomery
AL 36117
__________________________________________________________
agency address
___________________________________________________________
agency city county state zip
It is understood that the exemption from Federal Excise Tax in the case of sales of articles under this exemption certificate to a state, territory, or its political subdivision, or District of Columbia is limited to the sale of articles purchased for its exclusive use as described, and it is agreed that if articles purchased tax free under this exemption certificate are used otherwise, or are sold to employees or others, such fact will be reported by the undersigned or Governmental entity to ATK, for the article or articles covered by this certificate to secure exemption.
Use of this certificate, the evidence and records required to substantiate tax free or reduced tax rate sales and purchases, must be in accordance with applicable I.R.S. regulations.
I understand that the fraudulent use of this statement may subject me and all parties making such fraudulent use of this statement, to any applicable criminal penalties under the Internal Revenue Code.
__________________________________________ ____________________
Signature of Officer Date
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Merchandise description: Following is completed by Vendor
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Return this form via fax to Gulf States Distributors (334) 279 9267