Customer Application Form

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Issued to: Farmstead Foods, LLC 16182 Mount Zion Road Benton, IL. 62812. This is to certify that merchandise purchased by the undersigned from Farmstead Foods, LLC, for use in their operation has the following State Sales Use Tax Status.

I certify that the following is true *

Purchaser understands and agrees that if the purchase made under this certificate is used other than stated above for any purchase which would not exempt the sale within any of the designated jurisdictions, he becomes liable for the tax thereon and will pay such tax directly to the appropriate tax jurisdiction.

This certificate covers all future orders and is deemed valid until canceled by us in writing or as determined by state law. This certificate is considered valid if all requested information is provided and is correct.

Under penalties of perjury, I affirm that the information provided on this form is true and correct as to every material matter.

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