Looking for a Ct Tax Forms And Templates? Download it for free!

Form Cert-113 - Purchases Of Tangible Personal Property And Services By A Nonprofit Charitable Hospital, Nonprofit Nursing Home, Nonprofit Rest Home, Or Nonprofit Residential Care Home Page 2

Name of Purchaser

Address

CT Tax Registration Number

Exemption Permit Number

Federal Employer ID #

Name of Seller

Address

CT Tax Registration Number

Federal Employer ID #

Check One Box

Blanket Certificate

Certificate for One Purchase Only

Check Appropriate Box and Provide Written Description of Each Item Purchased

Tangible Personal Property

Service(s)

Description

Declaration by Purchaser

The nonprofit charitable hospital, nonprofit nursing home, nonprofit rest home, or nonprofit residential care home declares that the tangible personal

property or taxable services described above will be used exclusively for the purposes for which the organization was established and will not be resold

unless the purchase of tangible personal property or meals are for resale at one of the five fundraising or social events per year that are exempt from tax and

the institution is not, and is not required to be, a registered retailer with DRS. The organization further declares that the license with the Department of

Public Health attached to this certificate is active and valid and the state exemption permit or federal determination letter attached to this certificate has not

been cancelled or revoked.

According to Conn. Gen. Stat. §12-412(5) or Conn. Gen. Stat. §12-412(94), the purchase of the item(s) is exempt from sales and use taxes.

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 Purchasing Institution

By:

Authorized Signature of Owner or Officer

Title

Date

For More Information: Call Taxpayer Services at 1-800-382-9463 (in-state) or 860-297-5962 (from anywhere). TTY, TDD, and Text Telephone users

only may transmit inquiries anytime by calling 860-297-4911. Preview and download forms and publications from the DRS Web site at

CERT-113 (Back)

(Revised 01/05)