Form Cert-125 - Sales And Use Tax Exemption For A Motor Vehicle Purchased By A Nonresident Of Connecticut Page 2

Part II Retailer and Purchaser - Read instructions first, then complete Parts II, III, IV, and V.

Retailer Information

Name of retailer _____________________________________________________________________ CT Tax Registration No. _____________________

Street address _______________________________________________________________________ Date of sale ________________________________

City or town, State, ZIP Code __________________________________________________________ Telephone No. _____________________________

Purchaser Information

Name of Purchaser ________________________________________________ Daytime Telephone No. _________________________________________

If an individual:

If corporation, partnership, limited liability company, or other business entity:

Home address ___________________________________________________ Business address _______________________________________________

___________________________________________________

_______________________________________________

Name and address ________________________________________________ Name and address ______________________________________________

of employer

of partners,

________________________________________________

______________________________________________

officers,

________________________________________________

members, and

______________________________________________

operator(s) of

________________________________________________

______________________________________________

motor vehicle

Driver’s License Number

State

Expiration Date

Driver’s License Number

State

Expiration Date

(Attach copy of each out-of-state driver’s license. Use additional sheets if necessary for the names, addresses, and license numbers of additional drivers.)

Part III Motor Vehicle Identification Data

Year _________________ Model __________________ Make of vehicle _____________________________________ Color ______________

Vehicle identification number ___________________________________ State of registration and number __________________________________

Computation of Price

Trade-in Data

Gross sales price* ____________________________

Year ________________ Make ___________________ Model __________________

Trade-in allowance ___________________________

State of registration and plate number _________________________________________

Net sales price ______________________________

Vehicle identification number ________________________________________________

* Do not deduct manufacturer’s rebates from the gross sales price.

Part IV Purchaser’s Declaration

Please initial:

_______ I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, acknowledge that the retailer has explained to me the

meaning of a permanent place of abode as defined in Part I (or the requirements for business entities as described in Part I) and I declare that I do

not maintain such a permanent place of abode in Connecticut.

I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, declare that I purchased the motor vehicle described in Part III from

the retailer named in Part II. The purchaser is not a Connecticut resident and does not maintain a permanent place of abode in Connecticut, or the business entity

meets the requirements described in Part I. The purchaser is a resident of (or the business entity is located in) the State of __________________ . This motor

vehicle will not be presented, or is not required to be presented, for registration with the Connecticut DMV. I declare under the penalty of false statement that

I have examined this certificate and to the best of my knowledge and belief it is true, complete, and correct. I understand the penalty for wilfully delivering a false

return or document to the Department of Revenue Services (DRS) is a fine of not more than $5,000, or imprisonment for not more than five years, or both.

Signature of purchaser

or authorized person ________________________________________________ Date ________________________________________________________

If corporation, partnership, limited liability company, or other business entity:

Print name of purchaser

or authorized person ________________________________________________ Title _____________________________________

Date ___________

If jointly purchased,

signature of other purchaser __________________________________________ Print name of other purchaser ___________________________________

Part V Retailer’s Declaration

Please initial:

_______ I, an authorized agent of the retailer named in Part II, declare that I have explained to the purchaser that owning, leasing or otherwise maintaining

a permanent place of abode in Connecticut, even if it is not permanently occupied by the purchaser, subjects this purchase to Connecticut sales tax

and prohibits the use of this certificate. If the purchaser is a business entity, I have explained the exemption requirements for business entities set forth

in Part I, or if pertinent, I have explained the requirement for business entities to use this certificate as described in Part I.

I, an authorized agent of the retailer named in Part II, declare under the penalty of false statement that I have examined this certificate and to the best of my

knowledge and belief it is true, complete, and correct. I understand the penalty for wilfully 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 retailer’s authorized agent _________________________________________________________ Date _______________________________

Signature of retailer’s authorized agent ___________________________________________________________ Title _______________________________

CERT-125 (Back) (Rev. 07/06)