Form Cert-126 - Exempt Purchases Of Tangible Personal Property Or Services For Low And Moderate Income Housing Facilities Page 2
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2Name and Address of Low and Moderate Income Housing Facility
Name of Purchaser
Address
Connecticut Tax Registration #
Federal Employer ID #
(If none, explain)
Name of Seller
Address
Connecticut Tax Registration #
Federal Employer ID #
(If none, explain)
Purchaser is: Check Appropriate Box(es)
Sponsor
Owner
Operator
Contractor
of the facility named above.
If purchaser is a contractor, describe the purpose of the contract and identify the other contracting party or parties.
Provide written description of each item or service purchased.
Check one box:
Blanket Certificate
Certificate for One Purchase Only
You must attach a signed and dated copy of the DRS Facility Approval Letter identifying the housing facility to this certificate.
Declaration by Purchaser
The item(s) described above are tangible personal property or services to be incorporated into or used and consumed exclusively
in the operation of the low and moderate income housing facility identified above and in the attached Facility Approval Letter. I
declare that the purchaser named above is the sponsor, owner, or operator of the facility or a contractor under contract with the
sponsor, owner, or operator of the facility. 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 or services if any of the requirements
for the exemption under Conn. Gen. Stat. §12-412(29) are not present or are not met.
Declaration: 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-126 (Back)
(Rev. 01/05)
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