Arch, foot, and heel supports, gels, insoles, and cushions, excluding shoe reliners and pads
Artificial Limbs
Artificial Eyes
Artificial Noses and Ears
Abdominal Belts
Back Braces
Batteries, for use in Prosthetic and Orthopedic Appliances
Braces and Supports Worn on the Body to Correct or Alleviate a Physical Incapacity or Injury
Canes (all)
Crutches, Crutch Tips, and Pads
Dentures, Denture Repair Kits and Cushions
Dialysis Machines and Artificial Kidney Machines, Parts and Accessories
Fluidic Breathing Assistor
Hearing Aids (repair parts, batteries, wires, and condensers)
Heart Stimulators - External Defibrillators
Mastectomy Pads
Ostomy pouch and accessories
Patient Safety Vests
Portable Resuscitators
Rupture belts
Suspensories
Trusses
Urine collectors and accessories
Walking Bars
Walkers, including walker chairs
Wheelchairs, including powered models, their parts and repairs
EXEMPTION CERTIFICATE
MATERIALS AND SUPPLIES THAT BECOME A
COMPONENT PART OF A PRESCRIBED PROSTHETIC OR ORTHOPEDIC APPLIANCE
I, the undersigned individual, as a practitioner licensed in the State of Florida, or an authorized representative of a licensed prosthetist or a licensed orthotist, certify that the materials and supplies purchased on or after_______ (date) from ________ (Selling Dealer's Business Name) will be incorporated into and become a component part of a prosthetic or orthopedic appliance or device that will be dispensed pursuant to a prescription written by a licensed practitioner.
I understand that if I use the materials or supplies for any nonexempt purpose, I must pay tax on the purchase price of the item directly to the Department of Revenue.
I understand that if I fraudulently issue this certificate to evade the payment of sales tax, I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.
Under the penalties of perjury, I declare that I have read the foregoing Certificate and that the facts stated herein are true.
Name of Licensed Prosthetist or Orthotist: _______________________________________________________________________
Florida License Number: _________________________________________Address:_____________________________________
__________________________________________________________________________________________________________
Name of Authorized Representative: ____________________________________________________________________________
__________________________________________________________________________________________________________
(Signature of Licensed Prosthetist or Orthotist or Authorized Representative)
__________________________________________________________________________________________________________
Title
__________________________________________________________________________________________________________
Date
Fla. Admin. Code Ann. R. 12A-1.021
Rulemaking Authority 212.08(2)(a), (b), 212.18(2), 213.06(1) FS. Law Implemented 95.091(3), 212.06(1), 212.07(1), 212.08(2), 212.085, 212.12(6)(a), 213.37 FS.
New 10-7-68, Amended 1-7-70, 1-17-71, 6-16-72, 6-9-76, 6-26-78, 12-31-81, Formerly 12A-1.21, Amended 12-8-87, 7-12-10.