HOMETOWN FARM AND FEED, LLC KEEPIN' IT LOCAL TAX-EXEMPT CUSTOMER RECORD FORM Website CUSTOMER INFORMATION Customer / Business Name * Contact Person * Phone * Billing Address * City * State * ZIP * Email * TAX-EXEMPT INFORMATION Agricultural / Farming Resale Government Nonprofit / Organization Other If Other, please describe Name Listed on Certificate/Card * Tax-Exemption / Certificate Number * State / Issuing Authority * Expiration Date No expiration date shown SUPPORTING DOCUMENTATION UPLOAD TAX-EXEMPT CARD OR CERTIFICATE Upload a clear photo, scan, or PDF of the tax-exempt card/certificate. Accepted: JPG, PNG, PDF. Maximum 10 MB. Exemption certificate attached Additional supporting documentation attached Optional additional document CUSTOMER CERTIFICATION I certify that the information provided is accurate and that the tax-exemption documentation supplied to Hometown Farm and Feed, LLC is current and valid. I understand that exemption applies only to qualifying purchases and I will notify Hometown Farm and Feed, LLC if my status changes, expires, is revoked, or otherwise becomes invalid. Customer Signature (type full name) * Date * I certify and agree to the statement above. FOR HOMETOWN FARM AND FEED, LLC USE ONLY This section is intentionally omitted from customer input and can be completed internally after submission. Submit Tax-Exempt Information
