Bid document

Department of Revenue Services
State of Connecticut
450 Columbus Blvd Ste 1
Hartford CT 06103-1837

CERT-141

(Rev. 03/09)

Contractor’s Exempt Purchase Certificate
General Purpose: Contractors for the repair, alteration, improvement, remodeling, or construction of real property use this certificate to purchase materials and supplies to be installed or placed in a project being performed under contract with an exempt entity. The materials and supplies, including tangible personal property that remains tangible personal property after its installation or placement, must remain in the project after its completion. If the tangible personal property is not used in the manner described above, a contractor who claimed an exemption owes use tax on the total price of the tangible personal property.
Name of exempt entity
Address

Wherever the term contractor is used in this certificate, it includes subcontractors of the contractor performing a contract with an exempt entity.
Exempt entity means any person entitled to make purchases of tangible personal property exempt from sales and use taxes under the statutory authority listed in the instructions.

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Address of project
Type of exempt entity (See instructions.)

Name of purchaser
Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Name of seller
Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Provide a written description of each item purchased. Attach additional sheets if necessary.

Check one box:

r Blanket certificate

r Certificate for one purchase only

Declaration by Purchaser: The item(s) described above are tangible personal property to be installed or placed in a project being performed under contract with the exempt entity identified above and will remain in the project after its completion. I declare that the purchaser named above is a contractor under contract with the exempt entity or a subcontractor of the contractor. I acknowledge that the purchaser will be liable for Connecticut use tax, plus applicable penalty and interest as of the date of purchase, on the total purchase price of the property if any of the requirements for the exemption are not present or are not met. I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document