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MINNESOTA• REVENUE Operator Certificate of Compliance ST19 Read the information on the back before completing this certificate. Person selling at event: Complete this certificate and give it to the operator/organizer of the event. Operator/organizer of event: Keep this certificate for your records. Do not send this form to the Department of Revenue. • Name of business selling or exhibiting at event Minnesota tax ID number Seller's complete address City State Zip code Name of person or group organizing event Name and location of event Date(s) of event - Describe the type of merchandise you plan to sell. C -0 t4 O H 2 Complete this section if you are not required to have a Minnesota tax ID number. ❑ 1 am selling only nontaxable items. ❑ 1 am not making any sales at the event. ❑ 1 participate in a direct selling plan, selling for (name of company), and the home office or top distributor has a Minnesota tax ID number and remits the sales tax on my behalf. ❑ This is a nonprofit organization that meets the exemption requirements described below: Candy sold for fundraising purposes by a nonprofit organization that provides educational and social activities for young people primarily aged 18 and under (MS 297A.70, subd. 131-a](4]). Youth or senior citizen group with fundraising receipts of $10,000 or less per year (MS 29 7A. 70, subd. 13[b][1]). A nonprofit organization that meets all the criteria set forth in MS 297A.70, subd. 14. 1 declare that the information on this certificate is true and correct to the best of my knowledge and belief and that 1 am authorized to sign this form. Signature of seller Print name here Daytime phone ) PENALTY — Operators who do not have Form ST19 or a similar written document from sellers can be fined a penalty of $100 for each seller that is not in compliance for each day of the selling event. Stock No. 2100190 (Rev. 9/02)