Form Cert-105 - Commercial Motor Vehicle Purchased Within Connecticut For Use Exclusively In The Carriage Of Freight In Interstate Commerce Page 2

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Name of Purchaser
Address
CT Tax Registration Number
Federal Employer ID #
(If none, explain)
ICC Permit Number
Name of Seller
Address
CT Tax Registration Number
Federal Employer ID #
(If none, explain)
Vehicle Identification Data
Make of Vehicle
Model
Year
Color
Vehicle Identification Number
Manufacturer’s Gross Vehicle Weight Rating
Computation of Price
Trade-in Data
Gross Sales Price
Make
Model
Trade-in Allowance
Year
Net Sales Price
State of Registration and Plate Number
Vehicle Identification Number
Declaration by Purchaser
The motor vehicle described above is a commercial truck, truck tractor, tractor or semitrailer, or vehicle used in combination with these, which
will be operated actively and exclusively during the one-year period following the purchase date of such vehicle for the interstate carriage
of freight under a certificate or permit issued by the Interstate Commerce Commission (ICC) or its successor agency to the purchaser.
If the vehicle is not used in this manner during the period, the purchaser will be liable for Connecticut use tax on the total purchase price of
the vehicle.
As described in Conn. Gen. Stat. §12-412(70), the purchase of this motor vehicle 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 Purchaser
By:
Signature of Authorized Person
Title
Date
CERT-105 (Back)
(Rev. 01/05)

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