Click here to download the tax certificate (PDF) or complete the online form below:

1. If taxable, check box below, fill out Section 4, and sign below
2. All Items Purchase are Taxable

Section 1

1. Coverage of this purchase (check one)
2. One time Purchase Blanket Certificate
3. The purchaser hereby claims exemption on the purchase of tangible personal property and selected services made under this certificate from: mid-states bolt & screw co. (vendor) and certifies that this claim is based upon the customer's proposed use of the items or services, or the status of the customer.
4. **Blanket certificate is valid for three years from the date of the signature unless an earlier expiration date is noted.

Section 2: Items covered by this certificate

1. All items purchased
2. Or, limited to the following items:

Section 3: Basis for exemption claim

1. Resale
2. Out of State Customer At Retail* provide sales tax registration number below: At Wholesale Agricultural Production: Describe below Industrial Processing
3. Sales Tax Registration No.
4. Agricultural Production Descrition:
5. Non-Profit Organizations
6. Government Entity Non-Profit School Non-Profit Hospital Church Internal Revenue Code Section 501c3 Internal Revenue Code Section 501c4 Exempt letter from the State of Michigan
7. Other: explain

Section 4: Certification

1. In the event this claim is disallowed, the purchaser promises to reimburse the seller for the amount of tax involved.
2. Customer Name(required)
3. Address
4. City State Zip
5. Phone(required)
6. Fax
7. Your signature below authorizes mid-states bolt & screw co. to use the above information for purposes related to sales tax and your account.
8. Your Name (digital signature)(required)
9. Date(required)

 

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