Form Cert-141 - Contractor'S Exempt Purchase Certificate

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Department of Revenue Services
State of Connecticut
25 Sigourney Street Ste 2
Hartford CT 06106-5032
CERT-141
(Rev. 03/09)
Contractor’s Exempt Purchase Certifi cate
General Purpose:
Contractors for the repair, alteration,
Wherever the term contractor is used in this certifi cate, it includes
improvement, remodeling, or construction of real property use
this
subcontractors of the contractor performing a contract with an
certifi cate to purchase materials and supplies to be installed or placed
exempt entity.
in a project being performed under contract with an exempt entity.
Exempt entity means any person entitled to make purchases of
The materials and supplies, including tangible personal property
tangible personal property exempt from sales and use taxes under
that remains tangible personal property after its installation or
the statutory authority listed in the instructions.
placement, must remain in the project after its completion. If the
tangible personal property is not used in the manner described above,
a contractor who claimed an exemption owes use tax on the total
price of the tangible personal property.
Name of exempt entity
Address
CT Tax Registration Number
Federal Employer ID Number
(If none, explain.)
Address of project
Type of exempt entity (See instructions.)
Connecticut state government: Enter the exemption number.
Connecticut municipality
_________________________________
Charitable or religious organization: Enter the exemption number if any.
Federal government
______________________
Other (Explain.)
____________________________________________________________________________________________________
Name of purchaser
Address
CT Tax Registration Number
Federal Employer ID Number
(If none, explain.)
Name of seller
Address
CT Tax Registration Number
Federal Employer ID Number
(If none, explain.)
Provide a written description of each item purchased. Attach additional sheets if necessary.
Check one box:
Blanket certifi cate
Certifi cate for one purchase only
Declaration by Purchaser: The item(s) described above are tangible personal property to be installed or placed in a project being performed
under contract with the exempt entity identifi ed above and will remain in the project after its completion. I declare that the purchaser named
above is a contractor under contract with the exempt entity or a subcontractor of the contractor. I acknowledge 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 the property if
any of the requirements for the exemption are not present or are not met.
I declare under penalty of law that I have examined this 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 the Department of Revenue Services (DRS) is a fi ne of not more than $5,000 or imprisonment for not more than fi ve years, or both.
Name of purchaser
By:
Authorized signature
Title
Date

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