Form Cert-114 - Commercial Motor Vehicle Or Motor Bus Purchased Within Connecticut For Use In Interstate Commerce As An Interstate Motor Bus Certificate Form - Department Of Revenue Services, Connecticut Page 2

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Name of Purchaser

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Permit Number

Name of Seller

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Vehicle Identification Data

Make of Vehicle

Model

Year

Color

Vehicle Identification Number

Manufacturer’s Gross Vehicle Weight Rating

Number of Passengers (including driver)

Will this vehicle be used to transport students under age 21 to and from school?

Yes

Computation of Price

Trade-in Data

Gross Sales Price

Make

Model

Trade-in Allowance

Year

Net Sales Price

State of Registration and Plate Number

Vehicle Identification Number

Declaration by Purchaser

The vehicle described above is a commercial motor vehicle

as defined in Conn. Gen. Stat. §14-1(11)(A) and (B); or a motor bus as defined in Conn.

Gen. Stat. §14-1(44) that:

Will be operated as defined in Conn. Gen. Stat. §13b-88 or 13b-89; and

•

Will derive 75% of its revenue from its days in service from out-of-state trips or trips crossing state lines during the one-year period following the

•

purchase date of the vehicle.

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:

Signature of Authorized Person

Title

Date

CERT-114 (Back)

(Rev. 01/05)