D-16879 Ky Coalition to Abolish the Death Penalty
Exemption Number ‘Name of Exempt institution
Tnportant=Conificate not PURCHASE EXEMPTION Check Appiicabte Block
valid unless completed. CERTIFICATE ont
Single Purchase Oo
Ihereby certify thatKy Coalition to Abolish the DP_ is a Kentucky resident, nonprofit educational, charitable or
Name of Exempt Institution
religious institution, or Kentucky historical site, located at PO BOX 3092, Louisvilleentucky and that the tangible
personal property, digital property or services to be purchased from DELL
Name of Vendor
‘Address
will be used solely within the exempt function of a charitable, educational or religiou:
ion, or historical site.
Description of property to be purchased:_Computer equipment and/or software
In the event that the property purchased is not used for an exempt purpose, it is understood that | am required to
pay the tax measured by the purchase price of the property.
Any official or employee who uses this certificate to make tax-free purchases for his own personal use or that of
any other person will be subject to the penalties provided in KRS 139.990 and other applicable laws.
Under penalties of perjury, | swear or affirm that the information on this certificate is true and correct as to every
material matter.
let- Debahanty Board Chairperson
‘Authorized Signature Title
CAUTIONTO SELLER: This certificate canni6t be issued or used July 21, 2015
in any way by a construction contractor to purchase property Date
to be used in fulfilling a contract with an exempt institution.
Sellers accepting certificates for such purchases will be held DEPARTMENT OF REVENUE
liable for the sales or use tax. Frankfort, Kentucky 40620 51A126 (12-09)
