Name of Ag Retailer
Address
Phone
Farm Supply Input Exemption Certificate
Step 1: Identify the Seller
Name ____________________________________ Phone _______________________
Address ________________________________________________________________
Illinois Business Tax Number ______________________________________________
Step 2: Identify the Purchaser
Name ____________________________________ Phone _______________________
Address ________________________________________________________________
Date of Purchase ________________________
Step 3: Identify the agricultural production products being purchased.
Note: List the farm chemicals being purchased. In addition, if the products being purchased also include fertilizer, feed, seed or baby chicks, please list those products, for which the IDOR assigns the Resale Number 0110 to all buyers of these products for use in production agriculture. This document suffices as record of the purchase of these products being purchased for a tax exempt purpose.
________________________________________________________________________
________________________________________________________________________
Step 4: Sign Below
Under penalty of perjury, I state that I am utilizing these products for the production of an agricultural commodity and am purchasing these products sales tax exempt as defined in
86 Ill Administrative Code 130.1955 for farm chemicals and 86 Illinois Administrative
Code 130.2110 regarding sales of seeds, feed and fertilizer.
___________________________________________________ __________________
(Purchaser’s Signature) (Date)