Fill and Sign the Virginia Purchase Order Form

R-1070 (1/11) Application for Certification as a Manufacturer or Farmer for the Purpose of the Sales/Use Tax Exclusion for Manufacturing Machinery and Equipment Louisiana R.S. 47:301(3)(i), 301(3)(k), 301(13)(k)(i) and 305.25(A) Louisiana Department of Revenue Special Programs Division PO Box 4998 Baton Rouge, LA 70821-4998 Telephone: (225) 219-7462 • TDD: (225) 219-2114 Questions about the completion of this application should be sent to Sales. Inquiries@LA.GOV Please submit completed application to the Louisiana Department of Revenue, Special Programs Division at the address listed above. All applications must be accompanied by the applicant’s Federal Income Tax return. Part 1 Legal Name Trade Name Louisiana Plant Facility Address City State ZIP State ZIP Mailing Address City Contact Person Telephone Number Part 2 Louisiana Department of Revenue Account Numbers (List the account numbers for which this business is registered) *Businesses must have a Louisiana Sales Tax Account *Sales: Number prior to submission of this application. Online tax Withholding: registration is available at www.revenue.louisiana.gov. Corporate Income / Franchise: Part 3 Louisiana Workforce Commission Information Is this business required to register with the Louisiana Workforce Commission? (Agricultural employers that pay at least $20,000 in wages during a calendar quarter or employ at least 10 employees that work some portion of 20 or more weeks per year must register with LWC.) ❏ YES ❏ NO (If you answered no to this question, go directly to Part 4.) IF YES: Louisiana Workforce Commission Employer Account File Number: (Contact the LWC at (225) 342-3160 for assistance.) North American Industry Classification System (business activity code) Code issued by the LA Workforce Commission: ________________ (Use the North American Industry Classification System (NAICS) code issued to this location from the Multiple Worksite Report if this is a separate location.) (If you answered yes to the question above, go directly to Part 5.) Part 4 Businesses that are not required to register with the Louisiana Workforce Commission must provide the NAICS code listed on the most recently filed federal income tax return and include a copy of the federal form that shows this number. NAICS Code: ____________________________________________ Copy of form submitted: _________________________________________ New businesses that have not filed a federal income tax return prior to filing this application must submit a signed affidavit stating that the company will be primarily engaged in a business activity classified within the North American Industry Classification System. For information on the issuance of North American Industry Classification System codes, please contact the Louisiana Workforce Commission at (225) 342-3160. Part 5 Description of Business: (Attach additional sheet(s) if necessary.) Finished goods produced: Signature of Owner/Officer Title Date