Purchaser's Name* First Last Purchaser's Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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* CommentsThis field is for validation purposes and should be left unchanged.