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

Form Cert-111 - Machinery, Equipment, Materials, Tools, And Fuel Used By An Aircraft Manufacturer Operating An Aircraft Manufacturing Facility Page 2

Name of Purchaser

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Name of Seller

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Check One Box

Blanket Certificate

Certificate for One Purchase Only

Check Appropriate Box and Provide Written Description of Each Item Purchased

Machinery

Equipment

Materials

Tools

Fuel

Description

Declaration by Purchaser

The item(s) described on the front are machinery, equipment, materials, tools, or fuel as defined in Conn. Gen. Stat. §12-412(78) for use by an

aircraft manufacturer operating an aircraft manufacturing facility, as described in Conn. Gen. Stat. §12-412(78), in Connecticut.

In accordance with Conn. Gen. Stat. §12-412(78), the purchase of these 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 that 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-111 (Back)

(Rev. 01/05)

Form Cert-111 - Machinery, Equipment, Materials, Tools, And Fuel Used By An Aircraft Manufacturer Operating An Aircraft Manufacturing Facility Page 2