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Form Cert-127 - Exempt Purchases By An Enrolled Member Or By The Tribal Government Of The Mashantucket Pequot Tribe Or Mohegan Tribe Page 2

Name of Seller

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Check One Box

Blanket Certificate

Certificate for One Purchase Only

Check One Box

Property Purchased

Property Rented

Services Purchased

Description

Declaration by Purchaser

I declare that:

•

I am either an enrolled member or agent of the Mashantucket Pequot Tribe or the Mohegan Tribe purchasing tangible personal property

or services in Indian country of the tribe;

•

Title to the property or delivery of rented property will be taken in Indian country of the tribe (unless a Buy Connecticut permit is

provided); and

•

The property purchased or rented or the benefit of services purchased is realized in Indian country of the tribe and will be used

exclusively in Indian country of the tribe.

If, however, the tangible personal property purchased or rented under this certificate is intended to be used outside of Indian country of the

tribe or the benefit of services purchased under this certificate will be realized outside of Indian country of the tribe, I acknowledge that the

enrolled member or tribal government will be liable for Connecticut use tax on the total purchase price of the tangible personal property or

services if and when the tangible personal property is actually used or the benefit of the services are realized outside Indian country of the

tribe.

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 DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.

Print Name of Purchaser

Name of Tribe With Which the Purchaser Is Affiliated

By:

Signature

Title

Date

Enrolled Member

Agent of the Tribal Government

CERT-127 (Back)

(Rev. 01/05)

Form Cert-127 - Exempt Purchases By An Enrolled Member Or By The Tribal Government Of The Mashantucket Pequot Tribe Or Mohegan Tribe Page 2