Fillable Form St-5r - Contractor'S 5% Qualified Purchase Certificate

Form St-5r - Contractor'S 5% Qualified Purchase Certificate - 2009

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Rev. 7/09

Form ST-5R

Massachusetts

Contractor’s 5% Qualified

Department of

Purchase Certificate

Revenue

This form is to be used only for contracts entered into (1) before August 1, 2009, or (2) before October 1, 2009, if the contract is entered into in accord-

ance with a bid that had to be submitted before August 1, 2009. Not valid for use after December 31, 2010.

Part A. To be completed by purchasing contractor or subcontractor

Purchaser (

contractor

subcontractor)

Date

Address (must be in Massachusetts, unless registration certificate attached)

Vendor registration number (if applicable)

Approximate total dollar amount of contract

Contract/subcontract number

Contract/subcontract date

Bid date (if contract dated after August 1, 2009)