Cert-134, Exempt Purchase By Qualifying Governmental Agencies

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Purchaser is:





 United States

State of Connecticut

Name of agency

Name of agency (List exemption number, if any.)





 Federal credit union

Connecticut municipality

Name of credit union

Town or district and agency



 Other entity exempted by Connecticut law

Name of entity

Exempting Connecticut statute



 Other entity exempted by federal law

Name of entity

Exempting federal statute



or check box if acknowledgment letter from DRS is attached.

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 Connecticut Development Authority



 Agent of a qualifying governmental agency listed above (Attach documentation of appointment as agent.)

Name of agent:

Agent’s CT Tax Registration Number:

Agent’s Federal Employer ID Number:

Name of qualifying governmental agency:

Appointed agent for making the following types of purchases:

Address of purchaser:

Name of seller

Address

CT Tax Registration Number

(If none, explain.)

Federal Employer ID Number

Check one box:



Blanket certiﬁ cate (CERT-134 may not be used as a blanket certiﬁ cate for purchases of tangible personal property for resale at any one of ﬁ ve

fundraising or social events per calendar year exempt under Conn. Gen. Stat. §12-412(94). See below.)



Certiﬁ cate for one purchase only



Purchases that qualify for exemption under Conn. Gen. Stat. §12-412(94). Indicate the number of prior fundraising or social events during this

calendar year for which you claimed exemption under Conn. Gen. Stat. §12-412(94): _______________________

Check the appropriate box(es) and provide a written description of each item purchased:



Tangible personal property

Taxable services

Description:

Declaration by Purchaser

The item(s) described above are tangible personal property or services being purchased under the exemption provided in Conn. Gen. Stat. §12-412(1)(A)

or other applicable statute. The purchase of these items is exempt from sales and use taxes.

I declare under penalty of law that I have examined this certiﬁ cate (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 to DRS is a ﬁ ne of not more than $5,000 or

imprisonment for not more than ﬁ ve years, or both.

Name of purchaser

By:

Signature of authorized person

Title

Date

If the purchaser is an entity exempted under Connecticut law other than Conn. Gen. Stat. §12-412(1)(A), I have entered the citation of the exempting law

above. If the purchaser is an entity exempted under federal law, I have entered the citation of the exempting law above, or, if there is no speciﬁ c statutory

authority, I have attached a copy of the letter from DRS acknowledging the exempt status.

If the purchaser is an agent of a qualifying governmental agency, I have attached a copy of the document from the qualifying governmental agency expressly

designating the purchaser as agent.

CERT-134, Exempt Purchase by Qualifying Governmental Agencies (Rev. 07/09)

Connecticut Department of Revenue Services

Customer #

Client #

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