Cal. Code Regs. Tit. 18, div. 2, ch. 4, art. 3, app A
| EXEMPTION CERTIFICATE | STATE BOARD OF EQUALIZATION |
Qualified Sales and Purchases of Liquefied Petroleum Gas (LPG)
| SELLER'S NAME |
| SELLER'S ADDRESS (Street, City, State, Zip Code) |
The undersigned purchaser hereby certifies that the LPG will be used by a qualified person, as applicable, and in the manner as specified below (checkapplicable box and complete as necessary):
[]LPG used in a Household Activity* -- In accordance with Revenue & Taxation Code Section 6353(b), __________ % of the LPG purchased will be delivered by the seller into a tank with a storage capacity equal to or greater than 30 gallons for use in a household activity at the primary residence, which is not serviced by gas mains and pipes, of: 1) the purchaser; 2) a person described in Codes 0711 to 0783 of the Standard Industrial Classification (SIC) Manual, that assists a person engaged in an agricultural business described in Codes 0111 to 0291 of the SIC Manual ("qualified person"), or an employee of a qualified person where the LPG is purchased by such qualified person on behalf of the person that assists a qualified person in producing and harvesting agricultural products, or on behalf of the employee of that qualified person in producing and harvesting agricultural products; or 3) a renter or tenant where the LPG is purchased by a landlord or management company on behalf of the renter or tenant.
[]LPG used in an Agricultural Activity* -- In accordance with Revenue & Taxation Code Section 6353(b), __________ % of LPG purchased will be delivered into a tank with a storage capacity equal to or greater than 30 gallons and used in producing and harvesting agricultural products, and will be purchased by: 1) a person engaged in an agricultural business described in Codes 0111 to 0291 of the Standard Industrial Classification (SIC) Manual ("qualified person"); or 2) a person described in Codes 0711 to 0783 of the SIC Manual, that assists a qualified person; or 3) an employee of the qualified person.
* This certificate will be considered a blanket certificate for future purchases, unless otherwise specified. If this is a specific partial exemption certificate, provide the purchase order or sales invoice number in the following space:
__________
I understand that if the LPG is not used in the manner qualifying for the partial exemption, or if I am not a qualified person, as applicable, that I am required by the Sales and Use Tax Law to report and pay the state tax measured by the sales price of the LPG to me. I also understand that this exemption certificate is in effect as of the date shown below and will remain in effect until revoked in writing.
| PURCHASER'S NAME OR COMPANY NAME (If applicable) | DATE | |
| SIGNATURE (signature of the purchaser, purchaser's employee, or authorized representative of the purchaser) | PERMIT NUMBER (If applicable)1 | |
| TITLE | TELEPHONE NUMBER | |
| ADDRESS | CITY | STATE, ZIP |
1. If you are not required to hold a seller's permit, please enter "Not Applicable."
Cal. Code Regs. Tit. 18, div. 2, ch. 4, art. 3, app A