Form Cert-124 - Declaration By Purchaser printable pdf download

Form Cert-124 - Declaration By Purchaser

NAME OF PURCHASER

ADDRESS

CT TAX REGISTRATION NUMBER

FEDERAL EMPLOYER ID NUMBER

(If NONE, explain below)

NAME OF SELLER

ADDRESS

CT TAX REGISTRATION NUMBER

FEDERAL EMPLOYER ID NUMBER

(If NONE, explain below)

CHECK ONE BOX:

Blanket Certificate

Certificate for One Purchase Only

CHECK APPLICABLE BOX(ES):

Water Pollution Equipment

Supplies/Consumables

ITEMIZED DESCRIPTION OF ITEMS PURCHASED (FOR 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 for the

treatment of industrial waste before the discharge thereof into any waters of the state or into any sewerage system emptying into such

waters, the primary purpose of which is the reduction, control or elimination of water pollution, certified as approved for such purpose by

the Commissioner of the Department of Environmental Protection.

In accordance with Conn. Gen. Stat. §12-412(21), the purchase of these item(s) is exempt from sales and use taxes.

In accordance with Conn. Gen. Stat. §12-81(51), these items may be exempt from municipal property tax. Describe the items above and

include on the Declaration of Personal Property.

I declare under penalty of false statement that I have examined this Certificate and, to the best of my knowledge and belief, it is true,

complete and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand

dollars, or both.)

___________________________________

Name of purchasing business

BY: _________________________________________

________________________________

______________________

Authorized signature of owner or officer

Title

Date

CERT-124 (BACK)

(Rev. 6/99)

Form Cert-124 - Declaration By Purchaser