26 CAR pt. 37, Appendix A
I, ______ am engaged in the production of ( purchaser's name - please print )
Poultry as a commercial farming business. The water I am purchasing through the separate meter
No. ______ will be used exclusively in the commercial production of poultry on a poultry farm. I am aware that this claim for exemption will be reviewed by the Department of Finance and Administration. I am also aware that any false representation made by me in an attempt to purchase water free from Arkansas sales tax will result in the assessment of tax, penalty, and interest against me and is punishable as a misdemeanor under Arkansas law.
Signature of Purchaser
Date
Telephone Number
Address
City
State