Wisconsin Sales and Use Exemption Certificate

Please check below

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

Manufacturing _______________

Wholesaler __________________

Distributor __________________

Retailer _____________________


I hereby certify that I am engaged in the business as stated on this form




(Description of Property or Services Sold by Purchaser)


Sellers Name

Midway Machine LLC

Sellers Address

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.


Authorized Signature___________________________________

Title _____________________________________ Date____________