
DR 0563 (08/30/13)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0013
See page 2 for instructions
Last Name or Business Name First Name Middle Initial
Address
City State ZIP
I Certify That
Name of Firm (Buyer)
Address
City State ZIP
Wholesaler Retailer Manufacturer Charitable or Religious
Political Subdivision or Governmental Agency Other (Specify)
If Other, specify here
which are for resale or lease by us in the normal course of our business which is or
that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
Political Subdivision or Governmental Agency Charitable or Religious Otherwise Exempt By Statute (Specify)
If Otherwise Exempt By Statue, specify here
City or State State Registration or ID Number City or State State Registration or ID Number
City or State State Registration or ID Number City or State State Registration or ID Number
City or State State Registration or ID Number City or State State Registration or ID Number
General Description of products to be purchased from seller
Authorized Signature (owner, Partner or Corporate Oficer) Title Date (MM/DD/YY)
Which are for resale or lease by us in the normal course of our business which is _________________________or
that such purchases are exempt from payment of sales or use tax in such states and cities because our buyer is:
Use Tax we will pay the tax due direct to proper taxing authority when state law so provides or inform the seller for added
*130563==19999*