Form 72-340-10-8-000 - Mississippi Certificate Of Prime Contract Amount

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Form 72-340-10-8-000 (Rev. 5/10)
Mississippi
TO BE COMPLETED
Certificate of Prime Contract Amount
BY OWNER
See reverse for additional Instructions.
This form should be completed by the Owner prior to application for a
This form must be typed or printed.
Material Purchase Certificate.
Copies or reproductions of the official form are not acceptable.
This form must be signed before a notary public.
TO BE COMPLETED BY DEPARTMENT OF REVENUE
Sales Tax
Material Purchase
Account No. :
Certificate Number:
Contractor Information
Contractor Information
Contractor Information
Contractor's Name
Business Name (DBA)
Primary Address
City
State
County
ZIP
(
)
(
)
Phone
Ext.
Fax
Mailing Address (if different)
City
State
County
ZIP
(
)
(
)
Phone
Ext.
Fax
Owner Information
Owner Information
Owner's Name
Mailing Address
City
State
County
ZIP
(
)
(
)
Phone
Ext.
Fax
Date of Contract
Estimated Start Date
Estimated Completion Date
Description of work to be performed
Location of Job Site
City
State
County
ZIP
Estimated Contract Amount (round to the nearest whole dollar)...................................... $
I declare, under the penalties of perjury, that the above stated information has
This form must be signed before a notary public.
been examined by me and to the best of my knowledge and belief is true,
correct and complete.
Sworn to and subscribed before me, this
day of
,20
Signature of Owner or Representative
Title
Date
Signature of Notary
Mail To:
Department of Revenue
P.O. Box 1033
Date Commission Expires
Jackson, MS 39215

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