State Universal Fund Surcharge Exemption Certificate CUSTOMER is purchasing telecommunications services for resale in the states identified below. CUSTOMER certifies that is a telecommunications services provider and accepts responsibility for remitting State Universal Fund Surcharges, where applicable, directly to the proper authority in each jurisdiction. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri State USF or Registration Number State Montana Nebraska Nevada New Jersey New Hampshire New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State USF or Registration Number The undersigned Individual is authorized by CUSTOMER to make this certification on its behalf. Legal Name of Customer Address Authorized Signature Print Name Title Date Please return completed forms to: Attn: Regulatory Affairs, 3243 S. Meadowbrook, Springfield, IL 62711 or via e-mail to regulatoryaffairs@anpi.com
Multi-Jurisdiction Sales & Use Tax Exemption Certificate Issued to: ANPI, LLC, 3243 S. Meadowbrook Road, Springfield, IL 62711 Name/Address: I certify that, is registered and/or identified with the below listed cities and/or states within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product to be resold, leased, rented or used in the normal course of our business. We are in the business of wholesaling, retailing, manufacturing, leasing, renting or providing non-taxable services or products. Check applicable box: Single Purchase Certificate Blanket Certificate Is engaged as a registered (where applicable): Wholesaler Lessor Retailer Manufacturer Exempt Organization Use Other: Product or service rendered by Customer: Telecommunications Services State Registration or I.D. No. State Registration or I.D. No. Alabama 1 Mississippi Alaska Missouri 16 Arizona 2 USE STATE FORM 5000A Montana Arkansas Nebraska 17 California 3 Nevada Colorado 4 USE STATE FORM DR0563 New Jersey Connecticut 5 New Mexico 18 District of Columbia 6 New York USE FORM ST-120 & CT-120 Florida 7 FORWARD FL RESALE CERT North Carolina 19 USE STREAMLINED RESALE CERT E-595E Georgia 8 North Dakota Hawaii 4, 7 USE STATE FORM G-16 Ohio 20 Idaho Oklahoma 21 Illinois 1, 10 USE STATE FORM CRT-61 Pennsylvania 22 IL RT-2 Rhode Island 23 Illinois Excise Tax South Carolina Chicago Telecom South Dakota 24 Indiana Tennessee Iowa Texas 25 Kansas Utah Kentucky 11 USE STATE FORM 51A10 Vermont Louisiana Virginia Maine 12 Washington 26 FORWARD WA RESALE CERT Maryland 13 West Virginia Massachusetts Wisconsin 27 Michigan 14 Wyoming Minnesota 15 USE STATE FORM ST-5 For buyers with locations in states that do not require sales tax registrations, please check the appropriate box(es) and supply your federal EIN#: Alaska Delaware Montana New Hampshire Oregon EIN# I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a sales or use tax we will pay the tax due direct to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until cancelled by us in writing or revoked by the city or state. Exemption Claimed: Resale Federal Government Exempt Organization State & Local Government Direct Payment Permit Other: Please Specify I swear and affirm that the information on this form is true and correct as to every material matter. (Owner, Partner or Corporation Officer) Title Date
RESALE CERTIFICATE GROSS RECEIPTS TAX, SURCHARGES & TELECOMMUNICATION TAXES SELLER: PURCHASER: Address: ANY MODIFICATION TO THIS CERTIFICATE RENDERS IT NULL AND VOID ANPI, LLC. 3243 S. Meadowbrook Springfield, Illinois 62711 STATE REGISTRATION OR PERMIT NUMBER California (Note 1): Delaware: District of Columbia: Florida (Note 2): Hawaii: Illinois (Note 3): Maryland: New Mexico (Note 4): New York (Note 5): North Dakota: Ohio: Oregon PUC: Pennsylvania (Note 6): Rhode Island: Texas (Note 7: Virginia: Note 1 - Applicable to CPUC, ULTS, DEAF, CHCF, Teleconnect Fee and 911. Note 2 - Applicable to CST and Gross Receipts. Must have copy of pre-printed Resale Certificate. Note 3 - Applicable to Excise Tax, IMF and PUC. Note 4 - Applicable to TRS and Gross Receipts. Note 5 - Applicable to New York Section 186(e) only, (effective 1/1/95). Note 6 - Applicable to PUC and Gross Receipts. Note 7 - Applicable to Utility Gross Receipts Assessment, 911 and TIF. Effective date of this certificate: I certify that the above purchaser is registered with the above-listed state(s) and that services purchased after the Effective Date are purchased for resale, either wholesale or retail, in the normal course of the customer s business. I further certify that if any telecommunications service so purchased tax free is used or consumed by the Purchaser as to make it subject to tax, purchaser will pay the tax directly to the proper taxing authority when state law so provides or inform Seller for added tax billing. This certificate will be considered a part of each order which Purchaser may hereafter give to Seller and shall be valid until canceled by Purchaser in writing or revoked by the state. I declare under the penalties of false statements that this certificate has been examined by me and to the best of my knowledge and belief is a true, correct and accurate certificate. PURCHASER S AUTHORIZED SIGNATURE TITLE DATE PURCHASER S NAME (PRINT)