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MINNES~TA• REVENUE ST3
ertificate of Exemption
Purchaser: Complete this certificate and give it to the seller.
Seller: If this certificate is not fully completed, you must charge sales tax. Keep this certificate as part of your records.
This is a blanket certificate, unless one of the boxes below is checked, and remains in force as long as the purchaser continues
making purchases, or until otherwise cancelled by the purchaser.
Check if this certificate is for a single purchase and enter the related invoice/purchase order # .._._ _ ._._ .... _ __ .
If you are a contractor and have a purchasing agent agreement with an exempt organization, check the box to make multiple
- -= purchases for a specific job. Enter the exempt entity, name and specific project:
Exempt entity name Columbia Heights Public Library Project description Comcast business class Internet
Name of purchaser
Columbia Heights Public Library
.~
c
.~
a~
N
a
Business address City State
820 40th Ave NE Columbia Heights Mn
Purchaser's tax ID number State of issue Country of issue
802-1384 Minnesota USA
If no tax ID number, FEIN ' Driver's license number/State issued ID number
enter one of the following: ~ state of issue number
Name of seller from whore you are purchasing, leasing or renting
Comcast
Seller's address City State
Type of business. Circle the number that describes your business.
01 Accommodation and food services
02 Agricultural, forestry, fishing, hunting
w
03
Construction
.N
~ 04 Finance and insurance
~ 05 Information, publishing and communications
° 06 Manufacturing
m
~-
G7
fining
OS Real estate
09 Rental and leasing
10 Retail trade
11 Transportation and warehousing
12 Utilities
13 Wholesale trade
14 Business services
15 Professional services
16 Education and health-care services
17 Nonprofit organization
18 Government
19 Not a business (explain).... _. __.
20 Other (explain)
_..__ . .
Zip code
55421 _
zp ~<~de
Reason for exemption. Circle the letter that identifies the reason for the exemption.
A Federal government (deparunent)
0
''< B Specific government exemption (from list on back)
~ C Tribal government (name)
D Foreign diplomat #
y E Charitable organization # ._.__ _ _ _.... _._. _
~; F Religious or educational organization #
G Resale
H Agricultural production
I Industrial production/manufacturing
Direct pay permit #__.. _ ___ _...._
K Multiple points of use (services, digital goods, or
computer software delivered electronically)
L Direct mail
M Other (enter number from back page). ..._ _ __ __ _..
N Percentage exemption
I Advertising (enter percentage) `%
Utilities (enter percentage)
1 declare that the information on this certificate is correct and complete to the best of my knowledge and belief. (PENALLY- If
~, you try to evade paying sales tax by using an exemption certificate for items or services that will be used for purposes other
¢~ than those being claimed, you may be fined $100 under Minnesota !aw for each transaction for which the certificate is used.)
~ ~. a
~ ;Signature of authorized purchaser=' Print name here Title Date
N ~. ,~-'
- `t
..._ ~^°; ~-, ` 't.:` ~ ~' . ':..~`~ ~~V~ ~i~r-'(~y?.~,.(~ ~.G%~ Ct..`_.t! _ (_ _` ~ Y~ Y'Z ~_ ~'._t...~r.r ~ g~' ~"~ ~ ~ ~~~
Stock No. 2100030 (Rev. 6/08) Forms and fact sheets are available on our website at www.taxes.state.mn.us