Wisconsin Sales and Use Exemption Certificate
Single Purchase_________________Continuous ____________
Purchaserís Name _______________ ____________________
Purchaserís Address _____________ ____________________
Upon signing the bottom of this form, the purchaser claims exemption from Wisconsin State, County, Sales, and Use tax on the purchase, rental, or lease of tangible personal property or taxable services, according to the information on this form.
Permit or tax certificate number _____________________________
Please check the line that applies to purchaser
(Description of Property or Services Sold by Purchaser)
Midway Machine LLC
9832 Hwy 54 E
Wisconsin Rapids WI 54494
By signing this form, I certify that the item(s) purchased will be used in an exempt manner, and if not, will remit use tax at the time of first taxable use. I understand that failure to remit tax may result in a future liability that may include tax, interest and penalty.
Title _____________________________________ Date____________