Streamlined Sales and Use Tax Agreement Certificate of Exemption (Kansas)
This is a multi-state form. Not all states allow all exemptions listed on this form. Purchasers are responsible for knowing if they qualify
to claim exemption from tax in the state that would otherwise be due tax on this sale. The seller may be required to provide this
exemption certificate (or the data elements required on the form) to a state that would otherwise be due tax on this sale.
The purchaser will be held liable for any tax and interest, and possibly civil and criminal penalties imposed by the member state, if the
purchaser is not eligible to claim this exemption. A seller may not accept a certificate of exemption for an entity-based exemption on a
sale made at a location operated by the seller within the designate state if the state does not allow such an entity-based exemption.
1. Check if you are attaching the Multi-state Supplemental form.
If not, enter the two-letter postal abbreviation for the state under whose laws you are claiming exemption.
2.
Check if this certificate is for a single purchase and enter the related invoice/purchase order # .
3. Please print
Name of purchaser
Business Address City State ZIP
Purchaser’s Tax ID Number State of Issue Country of Issue
If no Tax ID Number FEIN Driver’s License Number/State Issued ID Number Foreign diplomat Number
Enter one of the following
State of Issue: Number
Name of seller from whom you are purchasing, leasing or renting
Seller’s Address City
State
ZIP
4. Type of business. Circle the number that describes your business
01 Accommodation and Food Services 11 Transportation and Warehousing
02 Agricultural, Forestry, Fishing, Hunting 12 Utilities
03 Construction 13 Wholesale Trade
04 Finance and Insurance 14 Business Services
05 Information, Publishing and Communications 15 Professional Services
06 Manufacturing 16 Education and Health-Care Services
07 Mining 17 Nonprofit Organization
08 Real Estate 18 Government
09 Rental and Leasing 19 Not a Business
10 Retail Trade 20 Other (explain)
5. Reason for exemption. Circle the letter that identifies the reason for the exemption.
A Federal Government (department) G Resale #
B State or Local Government (name) H Agricultural Production #
I Industrial Production/Manufacturing #
D Foreign Diplomat # J Direct Pay Permit #
E Charitable Organization # K Direct Mail #
F Religious or Educational Organization # L Other (explain)
6.
Sign here. I declare that the information on this certificate is correct and complete to the best of my knowledge and belief.
Signature of Authorized Purchaser Print Name Here Title Date
PR-78SSTA
(Rev. 10/09)
