Cert-117 1/05 - Purchases Of Tangible Personal Property Incorporated Into Or Consumed In Air Pollution Control Facilities - State Of Connecticut Department Of Revenue Services Page 2

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Name of Purchaser
Address
CT Tax Registration Number
Federal Employer ID Number
(If none, explain)
Name of Seller
Address
CT Tax Registration Number
Federal Employer ID Number
(If none, explain)
Blanket Certificate
Certificate for One Purchase Only
Check One Box:
Air Pollution Equipment
Supplies/Consumables
Check Applicable Box(es):
Itemized Description of Items Purchased (For the municipal property tax exemption, include date acquired, date installed, and purchase price. These
items must also be included on the Declaration of Personal Property):
Declaration by Purchaser
The item(s) described above are tangible personal property to be used or consumed by a business in the operation of facilities, the
primary purpose of which is the reduction, control or elimination of air pollution, certified as approved for such purpose by the
Commissioner of the Department Environmental Protection.
In accordance with Conn. Gen. Stat. §12-412(22), the purchase of these item(s) is exempt from sales and use taxes.
In accordance with Conn. Gen. Stat. §12-81(52), these items may be exempt from municipal property tax. Describe the items
above and include on the Declaration of Personal Property.
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 Purchasing Business
By: _____________________________________________
________________________________
________________
Authorized Signature of Owner or Officer
Title
Date
CERT-117 (Back)
(Rev. 01/05)

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