DR-97
                                 Suggested Format for an Exemption                                      R. 12/17 
                                 Certificate Based on Property’s Use

This is to certify that the tangible personal property purchased, leased, licensed, or rented; or services purchased on 
or after_______________(date) from _________________________________________(selling dealer’s business name) is 
purchased, leased, licensed, or rented for the following purpose as checked in the space provided below.
Note: This is not intended to be an exhaustive list.

o	 Materials, containers, labels, sacks, bags, or similar o	 Educational materials, such as glue, paper, paints, 
   items intended to accompany a product for sale at         crayons, unique craft items, scissors, books, and 
   other than retail, as provided in section (s.)            educational toys, purchased by child care facilities 
   212.02(14)(c), Florida Statutes (F.S.), by persons who    outlined in s. 402.305, F.S., that hold a current license 
   are not required to be registered under                   under s. 402.308, F.S., hold a current Gold Seal 
   s. 212.18(3), F.S.                                        Quality Care designation as provided in s. 402.281, 
o	 Incorporation into items of tangible personal property    F.S., and provide all employees with basic health 
   manufactured, produced, compounded, processed,            insurance as defined in s. 627.6699(12), F.S., as 
   or fabricated for one’s own use, as provided in Rule      provided in s. 212.08(5)(m), F.S.
   12A-1.043, Florida Administrative Code (F.A.C.).
                                                          o	 Motor vehicle rented or leased by a dealer who will 
o	 Printing of a publication exempt under the provisions     provide the motor vehicle at no charge to a person 
   of s. 212.08(7)(w), F.S.                                  whose motor vehicle is being repaired, adjusted, or 
                                                             serviced by the dealer, as provided in
o	 Items, such as paper and ink, that will be                s. 212.0601(4), F.S.
   incorporated into and become a component part of a 
   publication exempt under the provisions of
   s. 212.08(7)(w), F.S.
o	 Other (include description and statutory citation):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Note: There are other suggested formats for exemption certificates based on the use of the property or services that 
are provided in other sections of Rule Chapter 12A-1, F.A.C., and in Tax Information Publications (TIPs) issued by the 
Department.

 I understand that if I use the property or service for any nonexempt purpose, I must pay tax on the purchase or 
 lease price of the taxable property or service 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 penalty of 200 percent of the tax and may be subject to conviction of a third 
 degree felony.
 The exemption specified by the purchaser may be verified by calling 850-488-6800.
 Purchaser’s name:  ______________________________________________________________________________________
 Purchaser’s address:  _____________________________________________________________________________________
 Name and title of purchaser’s authorized representative:  ______________________________________________________
 By:  _____________________________________________________________________________________________________
     THIS FORM(Signature of purchaserCANNOTor authorized representative)             BE USED 
 Title:   _______________________________________________________________  Date:   _____________________________
     (Title – only if purchased by an authorized representative of a business entity)FOR RESALE PURPOSES

Reference: Rule 12A-1.038, F.A.C.