Form Cert-137 - Sales And Use Tax Certificate For Sale And Leaseback Arrangements - 2005 Page 2
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To Be Completed by the Purchaser
Name of Purchaser __________________________________________ CT Tax Reg. No. ________________________
Address of Purchaser _________________________________________________________________________________
Name of Retailer ____________________________________________
CT Tax Reg. No. _______________________
Address of Retailer ___________________________________________________________________________________
Name of Lessor _____________________________________________
CT Tax Reg. No. _______________________
Address of Lessor ___________________________________________________________________________________
Description of Property Purchased ______________________________________________________________________
Date of Original Sale ______________ Date of Sale and Leaseback Contract or Binding Agreement ________________
(The sale and leaseback contract or binding agreement must be signed within 120 days of the original sale.)
Date of Sale by Purchaser to Lessor ______________________ Sale:
Has
Has Not Occurred
Date of Leaseback Commencement ______________________ Leaseback
Has
Has Not Commenced
(The sale and leaseback must begin within one year of the original sale.)
Attached:
Sale and Leaseback Contract
Binding Purchaser/Lessor Letter
Bill of Sale (if needed)
Declaration by the Purchaser
The item described above is tangible personal property that is being or has been purchased under the sale and leaseback
exclusion or refund provisions of Conn. Gen. Stat. §12-407(a)(3)(B). Check one of the following:
The sale of this item is excluded from sales and use taxes because at the time of the original sale the purchaser provided the
retailer with the required evidence that within 120 days from the sale date the purchaser will enter into a sale and leaseback
agreement with a lessor;
The sales and use taxes paid on the sale of this item are being refunded to the purchaser by the retailer because the purchaser
provided the retailer with the required evidence that within 120 days from the sale date the purchaser will or has entered into
a sale and leaseback agreement with a lessor; or
The purchaser claims a refund from DRS of the sales and use taxes paid on the sale of this item because the purchaser
provided DRS with the required evidence that within 120 days from the sale date the purchaser will or has entered into a sale
and leaseback agreement with a lessor.
The sale of the item and the commencement of the leaseback have occurred or will occur within one year of the date of the
original sale.
I, the authorized representative of the purchaser named above, declare under penalty of law that I have examined the information
in this certificate 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 fine of not more than $5,000, or imprisonment for not more than five years, or both.
By: ________________________________________
_____________________________
_____________________
Signature of Authorized Person
Title
Date
CERT-137 (Rev. 01/05)
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