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PUBLICATION 146 | APRIL 2014 - page 35 / 38

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BOE-146-CC (BACK) (3-11)

STATEMENT OF DELIVERY

(to be completed by seller)

NOTICE TO SELLER

If you are delivering the materials or xtures to the Indian purchaser in Indian country by your own facilities, you may utilize this Statement of Delivery to document delivery in Indian country. It is recommended that you also complete the Notary Statement below to document delivery of the property to the Indian customer in Indian country. The Notary Statement may be completed by a California notary public or by a duly authorized tribal ofcial or his or her designee. If you are delivering the property to the Indian purchaser in Indian country by utilizing a common carrier or a contract carrier, you do not need to complete the Statement of Delivery or the Notary Statement. Instead, you should retain your bill of lading or other shipping documents as proof of delivery in Indian country along with your construction contract indicating ownership transferred in Indian country prior to installation.

I hereby certify, under penalty of perjury under the laws of the State of California, that the below described materials, xtures, or other tangible personal property was delivered to the purchaser in Indian country on the date and at the place stated below.

DESCRIPTION OF PROPERTY

INVOICE OR CONTRACT NUMBER

NAME OF RESERVATION

ADDRESS (street, cit , zip code)

DATE OF DELIVERY

NAME OF SELLER

SELLER’S PERMIT NUMBER

DAYTIME TELEPHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

I have delivered the above described tangible personal property to the purchaser named above.

NAME (please print)

SIGNATURE

DATE

NOTARY STATEMENT

(to be completed by California notary public or authorized tribal representative)

State of California

County of

On

(date)

before me,

(name and title)

, personally appeared

and

(name of seller or seller s representative)

(name of purchaser or purchaser s representative)

who proved to me on the basis of satisfactory evidence to the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

NOTARY SEAL

(if applicable)

I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and ofcial seal (if applicable).

Signature

Fraudulent use of this statement to avoid the payment of California sales and use tax can result in severe penalties.

APRIL 2014

|

SALES TO AMERICAN INDIANS AND SALES IN INDIAN COUNTRY



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