STATE OF LOUISIANA FORM LST -12 DEPARTMENT OF REVENUE AND TAXATION BLANKET CERTIFICATE FOR USE BY FOR HIRE CARRIERS OPERATING IN INTERSTATE OR FOREIGN COMMERCE UNDER THE LOUISIANA SALES TAX LAW R. S. 47:301 ET. SEQ. , 19 THIS CERTIFIES THAT ALL MATERIALS, EQUIPMENT, GOODS OR MERCHANDISE PURCHASED BY THE UNDERSIGNED FROM NAME ADDRESS are to be used or consumed in the undersigned's business of transporting passengers or property for hire in interstate or foreign commerce, and that all tax due will be paid by the undersigned directly to the Department of Revenue and Taxation, under the provisions of R. S. 47:306.1., as amended. REGISTRATION CERTIFICATE NUMBER poi/y) SIGNATURE OF PURCHASER ADDRESS //t) vrgvq- sa -vw/ / A!1k/ ìl7 .Jc Ax ay L (6-5e l/r/ dTVW' nocYD Any purchaser who fraudulently signs this certificate without intent to use the property or services purchased as above stated shall be subject to all penalties provided by Law. This certificate may not be offered or accepted in lieu of the tax on lease or rental transactions or on repair or other service transactions. R-1013 (R 4/79)
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