Signature of                      Purchaser

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ce Box) 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Retailer                                           North Dakota Sales & Use Tax Permit Number
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Print Address, City,
                                                                                                                                                                                                       Montana customer is in the state of North Dakota to make a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ZIP Code Of Purchaser             (No Post Offi

                                                                                                                                                                                                        (1) the 

                                                                                                                                                                                                       provided

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Print Name 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    means a natural person, corporation and other business entity when the owners, partners, or members are individual                                                                                                                                                                                                                                                                                                                                                                          

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Amount Of                         Purchase 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Person from Montana
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Request a form of identification, such as a Montana's driver's license, and insure the Certificate of Purchase is completed legibly.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              that I  am a resident of Montana in the state of North Dakota for the express purpose of making a purchase, as defined above.  I understand that 
CERTIFICATE OF PURCHASE -  EXEMPT SALES TO A PERSON FROM MONTANA NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER SFN 21854 (1-15)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Invoice Number 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Date Of                           Purchase 
                                                                                                                                                                                                       Sale of tangible personal property to a person from Montana is exempt                                                                                                                                                  specific purchase, (2) the sale of goods is fifty dollars or more and (3) the goods are removed from the state of North Dakota for use exclusively                     outside this state.                                                                                                 residents or domestic business entities from Montana. I Hereby Certify                                                                                                                                 falsification of this form to evade payment of tax is a class A misdemeanor and may be punishable by a fine up to $15,000, or imprisonment up to one year or both. Note To Retailer: