Miscellaneous Exemption Statement

MISCELLANEOUS EXEMPTION STATEMENT

WHEREAS

This Miscellaneous Exemption Statement (the Statement) is made between Claimant Name: and Requesting Party Name: .

WHEREAS, Claimant asserts that certain obligations or withholdings otherwise applicable to transactions or payments between the parties are subject to exemption for the reason(s) set forth herein; and

WHEREAS, the parties desire to record the basis, scope, and limitations of such exemption and the procedure for relying on the exemption for the duration stated below, effective as of: Effective Date:

EXEMPTION CLAIM

Claimant asserts the following basis for exemption (select all applicable and provide supporting detail as required):

Resale or resale certificate Government entity

Nonprofit / Charitable organization Independent contractor / classification

Other (explain)

SCOPE OF WORK

Describe the activities, goods, or services to which this exemption applies, including any limitations, project identifiers, invoice numbers, or contract references. If the exemption applies only to a portion of compensation or certain transactions, specify the portion and how it is calculated.

PAYMENT TERMS

TERM AND TERMINATION

This Statement begins on Start Date: and remains in effect until End Date: , unless earlier terminated as provided below.

Either party may terminate this Statement for material breach if the breaching party fails to cure within the notice period above. Termination does not relieve the parties of obligations that accrued prior to termination, including any payment obligations or obligations to preserve confidentiality.

CONFIDENTIALITY

The parties acknowledge that in the course of performing duties under this Statement either party may disclose Confidential Information. Each party agrees to hold Confidential Information in strict confidence and not to disclose it to third parties except as required by law or as expressly permitted in writing by the disclosing party. Confidential Information excludes information that is (a) already lawfully known to the recipient without obligation of confidentiality, (b) publicly available through no fault of the recipient, or (c) independently developed without use of the disclosing party's Confidential Information.

Special exclusions or permitted disclosures (if any):

GOVERNING LAW

This Statement and any dispute arising from it shall be governed by and construed in accordance with the laws of the state of , without regard to choice-of-law rules.

ENTIRE AGREEMENT

This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings, written or oral, concerning the exemption claimed. Any amendment must be made in writing and signed by both parties.

SUPPORTING DOCUMENTATION

List or describe documents provided to substantiate the exemption (certificates, letters of determination, organizational documents, invoices, contracts). Attach copies to any executed counterpart.

CERTIFICATION AND PENALTIES

By signing below, Claimant certifies that the information provided in this Statement is true, complete, and accurate to the best of Claimant's knowledge. Claimant acknowledges that knowingly providing false or misleading information may subject Claimant to civil or criminal penalties under applicable law and to reimbursement of any amounts improperly withheld or collected.

I certify under penalty of perjury that the exemption claimed above is authorized and applicable to the transactions described in this Statement.

CONTACT INFORMATION

Sign Now