Form Cert-139 - Sales And Use Tax Exemption For A Vessel Purchased By A Nonresident Of Connecticut - Department Of Revenue Services - State Of Connecticut Page 2

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Part II Retailer and Purchaser - Read instructions first, then complete Parts II, III, IV, and V.

Retailer Information

Name of retailer _____________________________________________________________________ CT Tax Registration No. _____________________

Street address _______________________________________________________________________ Date of sale ________________________________

City or town, State, ZIP Code __________________________________________________________ Telephone No. _____________________________

Purchaser Information

Name of purchaser ___________________________________________________________________ Daytime Telephone No. ______________________

If an individual:

If corporation, partnership, limited liability company, or other business entity:

Home address _________________________________________________ Business address _________________________________________________

_________________________________________________

Name and

_________________________________________________ Name and address _________________________________________________

address of

of partners,

_________________________________________________

employer

officers, members,

_________________________________________________

and operator(s)

of vessel

_________________________________________________

Driver’s License Number

State

Expiration Date

Driver’s License Number

State

Expiration Date

(Attach copy of each out-of-state driver’s license. Use additional sheets if necessary for the names, addresses, and license numbers of additional drivers.)

Part III Vessel Identification Data

Year _______________ Make of vessel ________________________________________ Model ________________________________________

Length _____________ Hull ID number _____________________________ State of registration and number _______________________________

Location of slip or mooring _________________________________________________________________________________________________

Computation of Price

Trade-In Data

Gross sales price* __________________________________

Make _____________________________ Model __________________________

Trade-in allowance _________________________________

Type ________________________ Length ______________ Year ___________

Net sales price ____________________________________

State of registration and number __________________________________________

* Do not deduct manufacturer’s rebates from

Hull ID number _______________________________________________________

the gross sales price.

U.S.C.G. vessel documentation number ____________________________________

Part IV

Purchaser’s Declaration

Please initial:

______

I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, acknowledge that the retailer has explained to me the

meaning of a permanent place of abode as defined in Part I (or the requirements for business entities as described in Part I) and I declare that I do

not maintain such a permanent place of abode in Connecticut.

I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, declare that I purchased the vessel described in Part III from the retailer

named in Part II. The purchaser is not a Connecticut resident and does not maintain a permanent place of abode in Connecticut, or the business entity meets the

requirements described in Part I. The purchaser is a resident of (or the business entity is located in) the State of _______________________ . This vessel will

not be presented for registration, or is not required to be registered, with the Connecticut DMV. I declare under the 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. 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.

Signature of purchaser

or authorized person ________________________________________________ Date ________________________________________________________

If corporation, partnership, limited liability company, or other business entity:

Print name of purchaser

or authorized person ________________________________________________ Title _____________________________________ Date ____________

If jointly purchased,

signature of other purchaser __________________________________________ Print name of other purchaser ___________________________________

Part V Retailer’s Declaration

Please initial:

_______ I, an authorized agent of the retailer named in Part II, declare that I have explained to the purchaser that owning, leasing or otherwise maintaining

a permanent place of abode in Connecticut, even if it is not permanently occupied by the purchaser, subjects this purchase to Connecticut sales tax

and prohibits the use of this certificate. If the purchaser is a business entity, I have explained the exemption requirements for business entities set forth

in Part I, or if pertinent, I have explained the requirement for business entities to use this certificate as described in Part I.

I, an authorized agent of the retailer named in Part II, declare under the 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. 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.

Print name of retailer’s authorized agent _________________________________________________________ Date _______________________________

Signature of retailer’s authorized agent ___________________________________________________________ Title _______________________________

CERT-139 (Back) (Rev. 07/06)