Form Cert-126 - Certificate For Exempt Purchases Of Tangible Personal Property Or Services For Low And Moderate Income Housing Facilities Page 2

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The item(s) described above are tangible personal property or services to be incorporated into or used and consumed exclusively in the operation of the

low and moderate income housing facility identified herein and in the attached Facility Approval Letter. I declare that the above-named purchaser is the

sponsor, owner or operator of the facility, or a contractor under contract with the sponsor, owner or operator of the facility. I acknowlege that the purchaser

will be liable for Connecticut use tax, plus applicable penalty and interest as of the date of purchase, on the total purchase price of such property or

services if any of the requirements for the exemption under Conn. Gen. Stat. §12-412 (29) are not present or are not met.

I hereby declare, under the penalties of false statement, that I have personal knowledge about the information contained herein and that, 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 purchaser

By: _______________________________________________________

__________________________________

___________________

Authorized signature

Title

Date

CERT-126 (Rev. 11/97)