Select Your Organization
Certified Treasurer Email
The exempt organization must be the direct purchaser and payer of record.
You may not use this form to purchase motor fuel or diesel motor fuel exempt from tax.
Representatives of governmental agencies or diplomatic missions may not use this form.
Carefully read the instructions and other information on the back of this document.
I certify that the organization named above holds a valid Form ST-119, Exempt Organization Certificate, and is exempt from New York State and local sales and use taxes on its purchases.
Certification: I certify that the above statements are true, complete, and correct, and that no material information has been omitted. I make these statements and issue this exemption certificate with the knowledge that this document provides evidence that state and local sales or use taxes do not apply to a transaction or transactions for which I tendered this document and that willfully issuing this document with the intent to evade any such tax may constitute a felony or other crime under New York State Law, punishable by a substantial fine and a possible jail sentence. I understand that this document is required to be filled with, and delivered to the vendor as agent for the Tax Department for purposes of section 1838 of the Tax Law and is deemed a document required to be filed with the Tax Department for the purpose of prosecution of offenses. I also understand that the Tax Department is authorized to investigate the validity of tax exclusions or exemptions claimed and the accuracy of the information entered on this document.