Dealer Registration Pack!
Dear Auto Dealer,
Thank you for choosing to do business with Brasher's Auto Group! Enclosed you will find all forms required to register with
Brasher’s Auto Auction. Also included is a list of the new Auction Access Fees, To be paid to Auction Access for a year membership. Please fill in all forms completely, making sure all Documents requiring signature are signed by an Owner or Authorized
Officer Of the company.
Please submit these completed forms & any additional Representative Authorization Letters along with the list of Documents
below:
__Legible copy of Motor Vehicle Dealer’s License
__Legible copy of Motor Vehicle Dealer’s Bond
__Legible copy of Dealer’s Sales Tax License
__Legible copy of Dealer’s Business License
__Legible copy of a Voided Company Check
Upon receipt of the completed documents, we will promptly process your Application and input your information into the
Auction Access Dealer Registration Database.
To better serve you while processing your titles please let us know what service you’d like to use.
Please mark which one and return to us.
__HOLD up front
__Mail Regular
__Mail Certified
__Mail Fedex
__Mail Overnight
__Other
On the Fedex and over night please include your account number. If you have any other questions or comments, please call
Brasher’s Dealer Registration Department @ 801-322-1234.
Sincerely,
Brasher’s Auction Group
All we sell is service but the service we sell is the best!
Brasher's Salt Lake Auto Auction
780 South 5600 West
Salt Lake City, UT 84104-5300
Toll Free: 800-426-4817
Office: 801-322-1234
Sales: 801-478-1800
Fax: 801-322-1315
Salt Lake Ph. 800.426.4817 - Fax 801.322.1315
Sacramento - Ph. 800.288.6882 - Fax 916.991.5445
Idaho:
Ph. 800.346.7839 - Fax 208.395.3157
Northwest Ph. 800.905.3901 - Fax 541.689.6049
Portland Ph. 800.300.3200 - Fax 503.492.0115
Reno Ph. 775.828.2437 - Fax 775.828.2438
San Jose Ph. 408.890.2990 - Fax 408.890.2991
GUARANTY, AGREEMENT & AUTHORIZATION
†
(“Dealer”) to
Legal Name of Dealership
buy and sell motor vehicles through Brasher's Auction Group, the undersigned, whether one or more, personally represent, warrant,
and unconditionally guarantee that the title to each vehicle sold by Dealer through Brasher's Auction Group will be good and will be
free and clear of all liens and encumbrances whatsoever. The undersigned unconditionally agrees to indemnify, hold harmless, and
reimburse Brasher's Auction Group for any loss, damage, expense, and costs, including attorney’s fees, incurred by Brasher's Auction
Group by any breach whatsoever of the foregoing warranty of title as to any such motor vehicle.The undersigned further guarantees
full payment of any debts of Dealer to Brasher's Auction Group, including any drafts issued by Dealer or any of Dealer’s agents,
together with any loss or expense incurred by Brasher's Auction Group in collecting or attempting to collect such debt, including
attorney’s fees. The undersigned acknowledges and agrees that Brasher's Auction Group shall have the right to refuse to transact
business with Dealer, to modify or release any and all collateral security, to extend or change time of payment and to settle or
compromise with Dealer without notice to the undersigned and without discharging or affecting the liability of the undersigned hereunder.
This guaranty is to be a continuing, non-terminable, irrevocable guaranty and the undersigned hereby waives notice of acceptance of
this guaranty and presentment, demand, protest and any notice of non-payment or dishonor. The undersigned shall be liable as
principal debtor and not merely as surety, and the bankruptcy or any assignment in favor of Creditors of Dealer shall not affect the
enforceability of this agreement. Dealer authorizes Brasher’s Auction Group to file a UCC-1 financing statement ‡ and any and all other
filings necessary to perfect Brasher’s Auction Group’s security interests with Dealer.
In consideration of Brasher’s Auction Group
allowing
By signing below, Dealer further represents and warrants that the above information in this dealership registration form, is true and
accurate and that all copies of bond(s), license(s), and any other information heretofore provided and that may be provided in the future
to Brasher's Auction Group by Dealer or any of its authorized agents or representatives is and will be true and accurate. In the event any
such information is false or inaccurate, Brasher's Auction Group, individually or collectively, and within their sole discretion, may
terminate any and all agreements with Dealer. In the event there is any transfer, assignment, or change in the indiviuals and/or entities
having an ownership interest in Dealer, Dealer agrees to immediately notify Brasher’s Auction Group in writing of such changes. The
undersigned further acknowledges and agrees that any and all information submitted by Dealer to any one affiliate of Brasher’s Auction
Group may be freely shared with any one or more of the other affiliates of Brasher’s Auction Group. Dealer authorizes Brasher’s Auction
Group to send Dealer promotional information from time to time via but not limited to facsimile, e-mail, direct mail, and telephone. The
undersigned understands and agrees that the liability of Dealer to the terms and conditions set forth herein, shall inure to the benefit of
each and every affiliate of Brasher’s Auction Group with whom Dealer transacts any business hereunder, but that the liability of Brasher’s
Auction Group to Dealer shall be specifically restricted and limited to the individual affiliate of Brasher’s Auction Group involved in each
transaction. Dealer certifies that Dealer holds valid seller’s permit, as listed above, issued pursuant to the sales and tax law of the state
where Dealer transacts business. Dealer certifies to be engaged in the business of selling vehicles (whether motorized, RV, trailers,
motorcycles, watercraft, and/or other goods of similar kind) and that the tangible personal property described herein which Dealer shall
purchase at Brasher’s Auctions will be resold by Dealer in the form of tangible personal property; provided however, that in the event any
of such property is used for any purpose other than retention, demonstration, or display while holding it for sale in the regular course of
business, it is understood that Dealer is required by state sales and use tax laws to report and pay tax, measured by the purchase price
of such property or other authorized amount. This instrument shall bind the respective heirs, executors, administrators and assigns of
the undersigned, and shall inure to the benefit of Brasher's Auction Group, its successors, assigns and subrogees. Where there is more
than one signatory to this agreement each signatory shall be jointly and severally liable under this agreement.
Name: _______________________________________
Printed
Signature: ____________________________________
Personally
Dated this _____ day of _________________, 20 ____
For: __________________________________________
Legal name of dealership
By: __________________________________________
Authorized Signature
Its: __________________________________________
Title of Authorized Signer
†
As used herein, as well as in any other documents pertaining to Dealer’s transactions with Brasher’s Auction Group, the term
“Brasher’s Auction Group” shall be defined as Brasher’s Auto Auctions, a Utah Corporation d/b/a Brasher’s Salt Lake Auto Auction;
Brasher’s Sacramento Auto Auction, Inc., a California Corporation, Brasher’s Northwest Auto Auction, Inc., an Oregon Corporation,
Brasher’s Cascade Auto Auction, Inc., an Oregon Corporation d/b/a/ Brasher’s Portland Auto Auction; Brasher’s Reno Auto Auction,
LLC, a Utah Limited Liability Company; Brasher’s Sacramento Auto Auction, Inc., a California Corporation d/b/a/ Brasher’s San Jose
Auto Auction; and any other affiliate now in existence or later acquired.
‡
Any UCC-1 financing statement filed by Brasher’s Auction Group shall have the following, or substantially similar, description of
collateral: All vehicle inventory, parts and accessories inventory, equipment, fixtures, accounts, holdback reserves, manufacturer
rebates and incentive payments, accounts, payment intangibles, instruments, securities and security accounts, and general intangibles
of the Debtor now owned and hereafter acquired, wherever located; all accessions to, substitutions for and all replacements of any of
the foregoing; all chattel paper, documents, instruments, monies, residues and property of any kind related to any of the foregoing;
all books and records of Debtor related to any of the foregoing, including without limitation, computer programs, print-outs, and other
computer hardware and software materials and records pertaining to any of the foregoing; together with all proceeds and products of
the foregoing, including, without limitation, proceeds of insurance policies insuring any of the foregoing ("Collateral").
Registration Application
Dealership Information
Dealership Auction ACCESS® ID:
Trade or DBA Name:
Legal Name (if different):
Date Business Started:
Government Business ID:
RIN (Canadian Province of Ontario only):
Company Type:
Sole Proprietorship
LLC-Partnership
General Partnership
LLC-Corporation
Limited Partnership
Sub C Corporation
LLC-Sole
Sub S Corporation
Business Types
Check all that apply
New
Used
Lease
Wholesale
Parts
Salvage
Export
Rental
Automobile
Motorcycle
Moped
RV
Mobile Home
Trailers (Pull Behind)
Motorcycle (Off Road)
ATV
Snowmobile
Heavy Equipment
Boats
Personal Watercraft
Airplanes
Contact Information
Lot Address:
City:
St/Prov (if applicable):
Colony (if applicable):
Postal Code:
Country:
Mailing Address:
City:
St/Prov (if applicable):
Bus. Phone Number:
Email Address:
Form No. 101 (Rev. 05/31/2007)
Colony (if applicable):
Postal Code:
Country:
Bus. Fax Number:
Website Address:
Page 1 of 2
© Copyright 1998-2007 AutoTec, LLC. All rights reserved.
Agreement
Dealership Auction ACCESS® ID:
The undersigned Entity (“Entity”) does hereby authorize AutoTec, LLC, its affiliates, and its customers that subscribe
to AutoTec’s Auction ACCESS system (including Manheim Auctions, Inc. and its subsidiaries, ADESA Corporation, LLC
and its subsidiaries, and all other current and future Auction ACCESS subscribing customers, as they may be enrolled
from time to time) (“Subscribing Customers”) to obtain, store, use and provide to Subscribing Customers the
information contained on this application and other information regarding the Entity, including credit information, such
as bank information and credit reports, and understands that AutoTec provides this information to said Subscribing
Customers without verifying the same, on an “as is” basis, expressly disclaiming any express or implied warranties
regarding such information. Subscribing Customers are not limited to businesses engaged in the automobile dealer or
auction industries, but may also include other businesses providing goods or services to such industries. By signing
below, the Entity (1) agrees to the terms of this application and any exhibits hereto, (2) warrants that it is solvent
and that the information provided herein is complete, accurate and truthful, (3) acknowledges that registration in the
Auction ACCESS system is no guarantee of purchasing privileges or credit, (4) agrees to be bound by the policies and
procedures of each Subscribing Customer at which they are registered via Auction ACCESS, (5) agrees that AutoTec,
LLC, its affiliates, and its Subscribing Customers may contact Entity, on their own behalf or on behalf of their
respective sellers, consignors, or other customers, for any commercial or advertising purpose, using the telephone
numbers (whether business, home or mobile numbers), fax numbers, e-mail addresses, and other contact information
provided on this form, or at any other address, telephone number, facsimile number or e-mail address used in
connection with Entity’s business, and (6) agrees to disclose Auction ACCESS numbers only to Subscribing Customers.
Each of the undersigned also agrees in his/her individual capacity that AutoTec, LLC, its affiliates, and its Subscribing
Customers may obtain, store, provide, and use that individual’s credit information, including bank information and
credit reports, in the same manner as described above for Entity.
Signature
Legal Name of Entity (Corp/LLC/LLP/Individual)
Trade or DBA Name of Entity
By:
Witness/Attester:
Printed Name of Authorized Signer (Owner/Officer/Manager)
Its:
Title of Authorized Signer (Owner/Officer/Manager)
Date:
Signature of Authorized Signer (Owner/Officer/Manager)
References
Auction Name
Phone Number
Franchise Information
Franchise Name
Form No. 101 (Rev. 05/31/2007)
Franchise Number
Franchise Name
Page 2 of 2
Franchise Number
© Copyright 1998-2007 AutoTec, LLC. All rights reserved.
Dealership Authorization of an Individual
Dealership Name:
Dealership AuctionACCESS ID:
Printed Legal Name of Individual
Individual's AuctionACCESS ID
Date of Birth
Add or Change Roles
By signing or clicking approval below, the dealership referenced above ("you”, “your”, or “yours”) authorizes AutoTec, LLC (“we”,
“us”, or “our”) to register the individual listed above ("Individual") to serve as your representative and agent in the following
capacity:
The role designated below will be the only role in effect for this Individual for this Dealership, replacing any previous
role authorization (check one).
Representative
Owner
Officer or Authorized Signatory
Driver
Subject to our acceptance of this authorization, you acknowledge the following: (i) the capacities in which the Individual is
authorized as your agent apply at and with us and our subscribing AuctionACCESS customers (“Customers”), including affiliates; (ii)
the authorization will be valid until one business day after we receive and process your written notice of termination in the form of a
Dealer Removal Letter; and (iii) once processed, the most recent authorization received and accepted by us will replace any prior
authorization(s) for the Individual for transactions thereafter.
If you designate the Individual in the capacity of “Representative,” “Owner,” or “Officer or Authorized Signatory” in this form, the
Individual may buy and sell automobiles for you and execute company checks, drafts, certificates of title, and/or any other
instruments or documents on your behalf at or with any Customer.
You guarantee performance of all obligations and payment of all debts incurred or authorized by this Individual on your account with
us or any Customer. This guaranty includes but is not limited to payment of losses from dishonored checks or drafts, defective titles,
or false or inaccurate Odometer Mileage Statements. You also guarantee that the Individual will conduct business with us and our
Customers in a fair and ethical manner, honoring all policies and procedures of each and respecting decisions of ours or our
Customers with respect to same. You will indemnify and hold harmless Customers, AutoTec, LLC, each’s affiliates, and the officers,
directors, employees, and agents of each of the foregoing, against any liability, loss, damages (including punitive damages), claim,
settlement payment, cost, expense, award, judgment, fee, or other charge, including reasonable attorneys’ fees, arising out of or
relating to the authorized Individual’s actions, as well as any expense incurred in attempting to collect such losses, including
attorney fees.
Our Customers are third-party beneficiaries of this authorization agreement. At their election, and in their sole discretion, they may
avail themselves of any provision of this agreement. However, this document is a supplement to, and not a replacement or
modification of, any agreement you have with those Customers, or any policies and procedures of such Customer.
Use of the AuctionACCESS System is open only to licensed dealers and their business associates and is a privilege, not a right. You
may authorize and register only those individuals who are bona fide employees or independent contractors for your dealership.
Retail buyers or others not affiliated with your business are not eligible to use the System. By signing or clicking approval below, you
also certify that the Individual is affiliated with your business and is eligible to use the System. We reserve the right to immediately
terminate any authorization obtained for ineligible persons and the right to terminate your AuctionACCESS membership if you
authorize a person who is not eligible to use the System, as well as the right to terminate either or both without cause in our sole
discretion.
Signature
By:
Its:
Printed Name of Authorized Signer
(Owner/Officer/Manager)
Title of Authorized Signer
(Owner/Officer/Manager)
Date:
Signature of Authorized Signer (Owner/Officer/Manager)
DAL Form (Rev. 02/06/2012)
© Copyright 1998-2012 AutoTec, LLC. All rights reserved.
Individual Authorization Letter
Agreement
Date:
Individual's AuctionACCESS ID:
To Whom It May Concern:
The individual referenced below (“Individual”) wishes to register, as of the date listed above, with AutoTec, LLC’s
AuctionACCESS System. The Individual does hereby authorize AutoTec, LLC, its affiliate Auction Insurance Agency,
and those of its customers that subscribe to AutoTec’s AuctionACCESS System (including Manheim Auctions, Inc. and
its subsidiaries, ADESA, Inc. and its subsidiaries, and all other customers subscribing to AutoTec’s AuctionACCESS
system) and to which Entity registers or otherwise provides its AuctionACCESS number at any time (“Subscribing
Customers”) to obtain, store, use and provide to Subscribing Customers the information contained on this form and
other information regarding the Individual, including credit information, such as bank information and credit reports,
and understands that AutoTec provides this information to said Subscribing Customers without verifying the same, on
an “as is” basis, expressly disclaiming any express or implied warranties regarding such information. Subscribing
Customers are not limited to businesses engaged in the automobile dealer or auction industries, but may also include
other businesses providing goods or services to such industries. By signing below, the Individual (1) agrees to the
terms of this registration and AutoTec's Terms and Conditions (as they may be amended from time to time) posted on
AuctionACCESS.com, (2) warrants that he/she is solvent and the information provided herein is complete, accurate and
truthful, (3) acknowledges that registration in the AuctionACCESS System is no guarantee of purchasing privileges or
credit, (4) agrees to be bound by the policies and procedures of each Subscribing Customer at which they are
registered via AuctionACCESS, (5) agrees that AutoTec, LLC, its affiliate Auction Insurance Agency, and its Subscribing
Customers may contact the Individual, on their own behalf or on behalf of their respective sellers, consignors, or other
customers, for any commercial or advertising purpose, using the telephone numbers (whether business, home or
mobile numbers), fax numbers, e-mail addresses, and other contact information provided on this form, or at any other
address, telephone number, facsimile number or e-mail address used in connection with the Individual’s business, and
(6) agrees to disclose AuctionACCESS numbers only to Subscribing Customers.
Date of Birth:
Government Personal ID:
Printed Legal Name of Individual
Individual Signature
Photo Identification
Driver's License
ID Number:
State/Province Issued ID
Passport
Voter Registration Card (Mexico Only)
State/Province or Country:
Issue Date:
Expiration Date:
Contact Information
Home Address:
City:
Colony (if applicable):
State/Province (if applicable):
Country:
Mobile Telephone:
IAL Form (Rev. 09/27/2010)
Postal Code:
Email:
Home Telephone:
© Copyright 1998-2010 AutoTec, LLC. All rights reserved.
AA Subscribing Customer:
Address:
City:
St/Prov:
Postal Code:
Phone:
Fax:
Bank Reference Letter
Auction ACCESS® Dealer ID: ______________________
Dealership Name: ________________________________ Owner/Officer Name:
Bank Name: _____________________________________ Account #:
Bank Address: ___________________________________ ABA#:
Bank City: _________________________________ State/Province: ______ Country: _______ Postal Code:
Bank Reference Phone:
Bank Reference Fax:
Attention Credit Department or Officer:
The aforementioned Dealership has listed your bank as its principal banking reference.
AutoTec, LLC has compiled and maintains a national database, Auction ACCESS®, which contains information on licensed new and used car
dealers for use by its automobile industry customers. Since the automobile auctions frequently guarantee dealer checks for cars bought at their
auctions, they require that all dealers who do business with the auctions establish their financial responsibility.
We would be grateful if you would check mark below your estimate of this account. This information will be incorporated into the Auction
ACCESS® database; otherwise, this information will be kept strictly confidential and will be used only for our purposes and the purposes of our
Subscribing Customers. Please return this completed letter directly to the above address.
Dealership has been banking with your bank since: _______________________
Type(s) of accounts held:
The Customer is:
Regular Account
Special Account
Loan Account
Account is:
Satisfactory
Unsatisfactory
Closed
Open Date:
Closed Date:
A valued customer with a good reputation and financial responsibility
Honest and reliable, but limited capital resources
Unknown to us
A new customer – our experience is limited
Average Balances for six months are: Low
Moderate
Negative Balance
Medium
High
3 figures
4 figures
5 figures
6 figures
Insufficient Checks or Drafts:
Overdrafts:
How Many?
How Many?
Does not issue
Does not issue
Maximum Credit recently extended:
$____________________________Secured
Do you floor plan this Customer?
Yes
$____________________________Unsecured
No
Floor Plan Line:
$________________New
$________________Used
Floor Plan Outstanding:
$________________New
$________________Used
Do you accept their Drafts? Yes No
Are all Drafts picked up within 48 hours? Yes No
Physical Address of bank for sight Draft: __________________________________________________________________________
Remarks: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Bank Official: ____________________________________
Title: _______________________________________
Print Name: ________________________________________________
Date: ________________ Phone: ________________
Thank you for your assistance.
BRL Form (Rev 04/02/2003)
Copyright © 2003 AutoTec, LLC. All rights reserved.
Bank Authorization Letter
To Whom It May Concern:
In order to enable my dealership to participate in AutoTec’s Auction ACCESS® System and thereby
enhance our wholesale automobile business and our ability to utilize our bank accounts in connection with
the same, I hereby authorize you to do the following:
♦
♦
♦
Release to the requesting Auction ACCESS Subscribing Customer, AutoTec, LLC and/or its affiliates
credit information.
Include the information contained in the attached Bank Reference Letter regarding my dealership and
its business checking and other accounts as requested by the Auction ACCESS Subscribing
Customer, AutoTec, LLC and/or its affiliates.
This information may be shared by any of the Auction ACCESS Subscribing Customers with whom I
wish to register.
The information will be used for business purposes in connection with the Auction ACCESS System
and/or affiliated programs provided for subscribing customers.
Auction ACCESS® Dealer ID: ______________________
Dealership Name:
________________________________________________________________
Dealership Address:
________________________________________________________________
________________________________________________________________
Your prompt attention in answering their Bank Reference Letter will be greatly appreciated.
Sincerely,
___________________________________
Dealership Name
By:
___________________________________
Name of Authorized Signer on Account Printed
Its:
___________________________________
Title
___________________________________
Signature of Authorized Signer on Account
BAL Form (Rev. 8/29/2003)
Copyright © 2003 AutoTec, LLC. All rights reserved.
Dealership Credit Information
Dealership Name:
Auction ACCESS Dealer ID:
Bank 1:
Name of Contact:
Address:
City:
Telephone #:
St/Prov:
Postal Code:
Country:
Fax #:
Routing #:
Date Opened:
Account #:
Bank 2:
Name of Contact:
Address:
City:
Telephone #:
St/Prov:
Postal Code:
Fax #:
Routing #:
Country:
Date Opened:
Account #:
Finance or Floor Plan:
Company:
Name of Contact:
Branch:
Address:
City:
Telephone #:
Floor Plan Account #:
St/Prov:
Postal Code:
Fax #:
Country:
Date Opened:
Floor Plan Credit Limit:
Account Opened:
Finance or Floor Plan:
Company:
Name of Contact:
Branch:
Address:
City:
Telephone #:
Floor Plan Account #:
St/Prov:
Postal Code:
Fax #:
Country:
Date Opened:
Floor Plan Credit Limit:
Account Opened:
Finance or Floor Plan:
Company:
Name of Contact:
Branch:
Address:
City:
Telephone #:
Floor Plan Account #:
Form DCI Rev (6/07/2006)
St/Prov:
Postal Code:
Fax#:
Floor Plan Credit Limit:
Country:
Date Opened:
Account Opened:
Copyright © 2006 AutoTec, LLC. All rights reserved.
W-9
Form
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
Individual/sole proprietor
C Corporation
S Corporation
Partnership
Trust/estate
Exempt payee
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶
Other (see instructions) ▶
Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
City, state, and ZIP code
List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Social security number
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Part II
–
–
–
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person ▶
Date ▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 12-2011)
Utah State Tax Commission • 210 N 1950 W • Salt Lake City, UT 84137
Print Form
Exemption Certificate
(Sales, Use, Tourism and Motor Vehicle Rental Tax)
Name of business or institution claiming exemption (purchaser)
Rev. 4/13
Telephone number
Street address
City
Authorized signature
TC-721
Clear form
State
Name (please print)
ZIP Code
Title
Date
Name of Seller or Supplier:
The signer of this certificate MUST check the box showing the basis for which the exemption is being claimed.
DO NOT SEND THIS CERTIFICATE TO THE TAX COMMISSION
Keep it with your records in case of an audit.
For purchases by government, Native American tribes and public schools, use form TC-721G.
❑
❑
❑
❑
❑
❑
❑
❑
RESALE OR RE-LEASE
Sales Tax License No. ________________
I certify I am a dealer in tangible personal property or services that
are for resale or re-lease. If I use or consume any tangible personal
property or services I purchase tax free for resale, or if my sales are
of food, beverages, dairy products and similar confections
dispensed from vending machines (see Rule R865-19S-74), I will
report and pay sales tax directly to the Tax Commission on my next
sales and use tax return.
LEASEBACKS
I certify the tangible personal property leased satisfies the following
conditions: (1) the property is part of a sale-leaseback transaction; (2)
sales or use tax was paid on the initial purchase of the property; and,
(3) the leased property will be capitalized and the lease payments will
be accounted for as payments made under a financing arrangement.
COMMERCIAL AIRLINES
I certify the food and beverages purchased are by a commercial
airline for in-flight consumption; or, any parts or equipment
purchased are for use in aircraft operated by common carriers in
interstate or foreign commerce.
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❑
❑
COMMERCIALS, FILMS, AUDIO AND VIDEO TAPES
Sales Tax License No. ________________
I certify that purchases of commercials, films, prerecorded video
tapes, prerecorded audio program tapes or records are for sale or
distribution to motion picture exhibitors, or commercial television or
radio broadcasters. If I subsequently resell items to any other
customer, or use or consume any of these items, I will report any tax
liability directly to the Tax Commission.
FILM, TELEVISION, VIDEO
I certify that purchases, leases or rentals of machinery or equipment will be used by a motion picture or video production company
for the production of media for commercial distribution.
ALTERNATIVE ENERGY
Sales Tax License No. ________________
I certify the tangible personal property meets the requirements of
Utah Code §59-12-104 and is leased or purchased by or for an
alternative energy electricity production facility, a waste energy
production facility, or a facility that produces fuel from alternative
energy.
FUELS, GAS, ELECTRICITY
Sales Tax License No. ________________
I certify all natural gas, electricity, coal, coke, and other fuel
purchased will be used for industrial use only and not for residential
or commercial purposes.
STEEL MILL
Sales Tax License No. ________________
I certify the rolls, rollers, refractory brick, electric motors or other
replacement parts will be used in the furnaces, mills or ovens of a steel
mill as described in Standard Industrial Classification (SIC) 3312.
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MUNICIPAL ENERGY
Sales Tax License No. ________________
I certify the natural gas or electricity purchased: is for resale; is
prohibited from taxation by federal law, the U.S. Constitution, or the
Utah Constitution; is for use in compounding or producing taxable
energy; is subject to tax under the Motor and Special Fuel Tax Act;
is used for a purpose other than as a fuel; is used by an entity
exempted by municipal ordinance; or is for use outside a municipality imposing a municipal energy sales and use tax. The normal
sales tax exemptions under Utah Code §59-12-104 do not apply to
the Municipal Energy Sales and Use Tax.
POLLUTION CONTROL FACILITY
Sales Tax License No. __________________________
I certify our company has been granted a “Certification of Pollution
Control Facilities” as provided for by Utah Code §§19-2-123 through
19-2-127 and as explained in Tax Commission Rule R865-19S-83
by either the Air Quality Board or the Water Quality Board. I further
certify each item of tangible personal property purchased under this
exemption is qualifying machinery or equipment for this purpose.
MEDICAL EQUIPMENT
I certify the equipment or device checked below is prescribed by a
licensed physician for human use.
❑ Durable Medical Equipment primarily used to serve a medical
purpose, is not worn in or on the body, and is for home use
only. (Sales of spas and saunas are taxable.)
❑ Mobility Enhancing Equipment primarily used to improve
movement, is for use in a home or motor vehicle, and is not
used by persons with normal mobility.
❑ Prosthetic Device used to replace a missing body part, to prevent
or correct a physical deformity, or support a weak body part. This
is also exempt if purchased by a hospital or medical facility.
(Sales of corrective eyeglasses and contact lenses are taxable.)
❑ Disposable Home Medical Equipment or Supplies that
cannot withstand repeated use and purchased by, for, or on
behalf of a person other than a health care facility, health care
provider or office of a health care provider. The equipment
and supplies must be eligible for payment under Title XVIII,
federal Social Security Act, or the state plan for medical
assistance under Title XIX, federal Social Security Act.
RELIGIOUS OR CHARITABLE INSTITUTION
Sales Tax License No. ________________
I certify the tangible personal property or services purchased will be
used or consumed for essential religious or charitable purposes.
This exemption can only be used on purchases totaling $1,000
or more, unless the sale is pursuant to a contract between the
seller and purchaser.
DIRECT MAIL
Sales Tax License No. ________________
I certify I will report and pay the sales tax for direct mail purchases
on my next Utah Sales and Use Tax Return.
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form
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