here - Illinois Fertilizer and Chemical Association

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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)

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