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Form Cert-132 - Sales And Use Tax Exemption For Purchases Made Under The Buy Connecticut Provision Page 2

Name of Purchaser

Address

Connecticut Tax Registration #

Federal Employer Identification #

(If none, explain)

Name of Seller

Address

Connecticut Tax Registration #

Federal Employer Identification #

(If none, explain)

Check One Box:

Blanket Certificate (Through end of calendar year)

Certificate for One Purchase Only

Describe the Tangible Personal Property Purchased:

Declaration by Purchaser

The item(s) described on this certificate are tangible personal property being purchased exempt from sales and use taxes by an

entity carrying on a trade, occupation, business, or profession in Connecticut with a valid Buy Connecticut Provision Exemption

Permit. A copy of the permit is attached to this certificate.

Declaration: I declare, under the penalty of false statement, that I am an owner or officer of the purchaser, and that I have

personal knowledge about the information contained in this certificate. I declare under penalty of law that I have examined

this return or 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.

Name of Purchaser

By:

Authorized Signature

Title

Date

CERT-132 (Rev. 01/05)

Form Cert-132 - Sales And Use Tax Exemption For Purchases Made Under The Buy Connecticut Provision Page 2