Examples of completed forms

01-924 Texas Agricultural Sales and Use Tax Exemption ...

All other purchases of agricultural items require this properly completed form to claim a sales tax exemption. See the back of this form for examples of exempt and taxable items. Name of retailer Address (Street and number, P.O. Box or route number) City, State, ZIP code Proper use of this certificate Purchasers

  Example, Completed

Over-the-Counter (OTC) Items

Please note that this is not a complete list, but is intended to provide Plan participants with examples to help determine what OTC items may be an eligible expense. Limited Medical FSA/HRA Plan participants should check their Plan Highlights to see if OTC items are eligible. Up-to-date information is available at BenefitResource.com.

  Example

CERTIFICATE OF ACKNOWLEDGMENT

Page 1 of 1 CERTIFICATE OF ACKNOWLEDGMENT The State of Texas County of _____ Before me, _____ (insert the name and character of the