Directions for setting up tax exempt status with us. 1. Right click on the form below and select PRINT. This allows you to print this form. Fill it out, sign, date it and either fax it back to us or scan the     document and e-mail it back. To e-mail us, click on Home above and then click on our e-mail address at the upper top left of the Home Page.     Be sure to add the signed Tax Exemption Certificate document as an e-mail attachment. 2. If you prefer to fax the document, use the following number: 1-765-643-1061. Our fax is usually turned off, therefore you should call us     before faxing the document. 3. You may also mail the document to us at PSI Dental Supply, P.O. Box 269, Chesterfield, IN 46017-0269

Form ST- 105          Indiana Department of Rcvcnue State Form 49065 R4/ 8-05     General Sales Tax Exemption Certificate Indiana registered retail merchants and businesses located outside Indiana may use this certificate. The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for purchases from Indiana vendors. This exemption certificate can not be issued for the purchase of Utilities, Vehicles, Watercraft, or Aircraft. Purchaser must he registered with the Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unless all information in each section is fully completed by the purchaser. Purchasers not able to provide all required information must pay the tax and may file a claim for refund (Form ( GA-1101,) directly with the Department of Revenue. SECTION 1 (print only)  Name of Purchaser ____________________________________________________________________________________  Business Address ____________________________________ City  _________________ State  _________  Zip _________  Purchaser must provide minimum of one ID number below.*  Provide your Indiana Registered Retail Merchant's Certificate  TID and LOC Number as shown on your Certificate....................................____________________________ -- _____________                                                                                                                                                        TID# (10 digit)                        LOC# (3 digits)  If not registered with the Indiana DOR, provide your State Tax  ID Number from another State................................................................................________________________________________  *See instructions on the reverse side if you do not have either number.         State ID#                                        State ot Issue SECTION 2 (Check one) Is this a |_| blanket purchase exemption request or a |_|single purchase exemption Request? (check one) Description of items to be purchased. ________________________________________________________________________ SECTION 3 Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain) |_| Sales to a retailer, wholesaler, or manufacturer for resale only. |_| Sale of manufacturing machinery, tools, and equipment to be used directly in direct production. |_| Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin # 10.          (May not be used for personal hotel rooms and meals.) |_| Sales of tangible personal property predominately used (greater than 50 percent) in providing public transportation - provide         USDOT#.  A person or corporation who is hauling under someone else's motor carrier authority, or has a contract as a school         bus operator, must provide their SS# or FID# in lieu of a state ID# in Section # 1.   USDOT# ________________________ |_| Sales to persons occupationally engaged as farmers, to be used directly in production of agricultural products for sale.        Note: A farmer not possessing a State Business License# may enter a FID# or a SS# in lieu of a State ID# in Section # 1. |_| Sales to a contractor for exempt projects (such as public schools. goveninlent. or nonprofits). |_| Sales to Indiana Governmental Units (agencies. Cities. towns. municipalities, public schools, and state universities). |_| Sales to the United States Federal Government - show agency name. _____________________________________________         Note: A U.S. Government acency should enter its Federal Identification Number FlD#) in Section #1 in lieu of a State ID#. |_|  Other - explain. ________________________________________________________________________________________ SECTION 4 I hereby certify under the penalties ot perjury that the property purchased by the use ot this exemption certilIcate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5. and the item purchased is not a utility, vehicle, watcrcratt, or aircraft. I confirm my understanding that misuse. (either negligent or intentional). and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the imposition of tax, intetest. and civil and/or criminal penalties.        Signature ol Purchaser ____________________________________________________________Date ___________________        Printed Name__________________________________________________________Title______________________________ The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller must keep this certificate on file to support exempt sales.