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Form Cert-109 - Partial Exemption For Machinery, Equipment, Or Repair And Replacement Parts Page 2

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)

Check One

Blanket Certificate

Certificate for One Purchase Only

Description of Machinery, Equipment, Replacement Parts, or Repair Parts

Declaration by Purchaser

The items described above are machinery, equipment, or repair or replacement parts to be used primarily in the process of manufacturing, processing or

fabricating, as defined in Conn. Gen. Stat. §12-412i.

According to Conn. Gen. Stat. §12-412i, the purchase of these items is subject to a partial exemption 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 Company

By:

Authorized Signature of Owner or Officer

Title

Date

CERT-109 (Back)

(Rev. 01/05)

Form Cert-109 - Partial Exemption For Machinery, Equipment, Or Repair And Replacement Parts Page 2

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