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City of Fort Collins BLANKET EXEMPTION CERTIFICATE
(For use by States, Territories, or political subdivision thereof)
Date: May 19, 2004
The undersigned hereby certifies that she is Joyce Grenz, Accounts Payable
Representative of City of Fort Collins to execute this certificate and that the article or
articles specified in the accompanying orders, or on the reverse side hereof, are purchased
from nash—elmo Industries LLC for the
exclusive use of the City of Fort Collins of the State of Colorado.
It is understood that the exemption from tax in the case of sales of articles under this
exemption certificate to a State, etc., is limited to the sale of articles purchased for its
exclusive use, and it is agreed that if articles purchased tax free under this exemption
certificate are used otherwise or are sold to employees or others, such fact will be
reported by me to the manufacturer of the article or articles covered by this certificate. It
is also understood that the fraudulent use of this certificate to secure exemption will
subject the undersigned and all guilty parties to a fine of not more than $10,000.00 or to
imprisonment for not more than five years, or both, together with costs of prosecution.
State of Colorado Department of Revenue, Certificate of Exemption
Identification Number 98-04502.
z
(Signature)
Accounts Payable ReD — Accountiniz Dent.
(Title of Officer)
215 North Mason Street • 2nd Floor • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6788 9 FAX (970) 221-6782