1. I hold a valid Seller's Permit or Certificate of Registration -- Use Tax

[ ] Yes. Seller's Permit or Certificate of Registration. -- Use Tax number:

[ ] No.

If you responded “No” to item number one, please complete item number two.

2. Reason for not holding a Seller's Permit or Certificate of Registration -- Use Tax:

3. General description of the batteries covered by this certificate:

4. I am claiming an exclusion or exemption from the following fee(s) (check all that apply):

5. Each battery purchased is not subject to the lead-acid battery fee(s) for one or more of the following reasons

[check all that apply]

[ ] Purchased for resale. (Only applies to the California Battery Fee.)

[ ] A replacement lead-acid battery that will be temporarily stored or used in California for the sole purpose of preparing the battery for use solely outside of California and will be subsequently transported outside the state and thereafter used solely outside of the state.

[ ] A battery to be incorporated into new equipment to be resold with the battery.

[ ] A battery to be incorporated into a used vehicle sold or leased by a new motor vehicle dealer. (Only applies to the California Battery Fee)

[ ] A battery to be provided as a replacement, without charge, under a vehicle or battery warranty or a vehicle service contract described under Insurance Code section 12800.

[ ] A battery to be used with or contained within a medical device, as defined in 21 U.S.C. 321(h).

[ ] A battery to be used as a stationary storage or standby battery that is designed to be used in systems where the battery acts as either: (Only applies to the California Battery Fee)

• Electrical storage for electricity generation equipment;

• A source of emergency power; or

• Otherwise serves as a backup in case of failure or interruption in the flow of power from the primary source.

6. I certify that the batteries I am purchasing under this exclusion and exemption certificate are not subject to the lead-acid battery fee(s) due to the exclusion(s) and/or exemption marked above and that the lead-acid batteries will be used as certified. I understand that if any lead-acid batteries are sold or used in a manner or for a purpose not specified above, I am required to report and pay any applicable lead-acid battery fees, including interest and penalties (if applicable), directly to the California Department of Tax and Fee Administration.