01-919 
       (7-05)                                            STATE OF TEXAS

TEXAS DIRECT PAYMENT EXEMPTION CERTIFICATION                                                     Direct payment permit number 
LIMITED SALES, EXCISE AND USE TAX 

Name of purchaser, firm or agency 

Address (Street & number, P.O. Box or Route number)                           Phone (Area code and number) 

City, State, ZIP code 

I, the undersigned, hereby claim an exemption from payment of state, city, county, special purpose district, and transit 
authority/department sales and use taxes upon purchase of taxable items from: 

Seller: 

Street address:                                                           City, State, ZIP code: 

Description of items to be purchased (If this space is left blank, this certificate covers everything on the attached order, invoice, 
or billing): 

This certificate does not cover: 

(1) Purchases of taxable items to be resold; 

(2) Sales or rentals to any purchaser other than the permit holder; 

(3) Sales or rentals of motor vehicles subject to the motor vehicle sales and use tax (Chapter 152); 

(4) Materials or supplies used, transferred, or consumed by a provider of a nontaxable service selling the service to a direct 
        payment permit holder. 

This certificate is not valid for lump-sum new construction projects to improve real property for a direct payment permit holder. 

The permit holder agrees not to permit others (including its contractors and repairmen) to use the undersigned’s direct 
payment authorization to purchase materials tax-free. 

The undersigned agrees to accrue and pay the tax to the Comptroller of Public Accounts as required by statute. 

       Authorized signature                                 Permit holder                        Date 

This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts.