Cert-101, Machinery, Component Parts, And Replacement And Repair Parts (Page 2 of 2) in pdf

Cert-101, Machinery, Component Parts, And Replacement And Repair Parts Page 2

Name of Purchaser

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Name of Seller

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Check One Box:

Blanket Certificate

Certificate for One Purchase Only

Description of Machinery, Component Parts and Contrivances, or Replacement and Repair Parts

Declaration by Purchaser

The item(s) described on this certificate are:

•

Machinery to be used directly in the manufacturing production process, as defined in Conn. Gen. Stat. §12-412(34) and Conn.

Agencies Regs. §12-412(34)-1;

•

Component parts and contrivances that are used or required to control, regulate, or operate the machinery, or to enhance or alter its

productivity or functionality;

•

All replacement and repair parts for this machinery or its component parts and contrivances; or

•

Component parts of a machine purchased exclusively for the purpose of assembling a machine for use directly in a manufacturing

production process as described in Conn. Gen. Stat. §12-412(73) .

In accordance with Conn. Gen. Stat. §12-412(34) or (73), the purchase of the described items is exempt from sales and use taxes.

Declaration: I declare under penalty of law that I have examined this return or 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 to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.

Name of Purchaser

By:

Authorized Signature of Owner, Agent, or Officer

Title

Date

CERT-101 (Back)

(Rev. 01/05)

Cert-101, Machinery, Component Parts, And Replacement And Repair Parts Page 2