Agricultural Exemption Form

Purchaser's Name*

First Last

Purchaser's Address*

Street Address Address Line 2 City State ZIP Code

Account Number(s)*

Purchaser's Consent*

I hereby verify the above information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

Purchaser's Exemption Certificate for Electricity Used Directly and Exclusively in Production or Processing of Agriculturer Products on a Farm

I certify that the electricity purchased on or after from Gulf Coast Electric Cooperative will be used directly and exclusively for production of processing of agricultural farm products on a farm and is exempt from sales tax pursuant to Section 212.08(5)(e)2., Florida Statutes.

I understand that if the electricity purchased does not qualify for exemption under Section 212.08(5)(e)2., Florida Statutes, that I must pay the tax on the purchase directly to the Department of Revenue.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax, plus a mandatory penalty of 200% of the tax, and will be liable for fine and punishment provided by law for conviction of a felony of the third degree, as provided in s. 775.082, s. 775.083, or s. 775.084, F.S.

Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.

Purchaser's Electronic Signature (Full Name)*

Purchaser's Title*

Name

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