Form Cert-104 - Services Certificate For New Construction (Page 2 of 2) in pdf

Form Cert-104 - Services Certificate For New Construction Page 2

Name of Service Recipient

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Name of Service Provider

Address

CT Tax Registration Number

Federal Employer ID #

(If none, explain)

Location of Affected Property

General Description of Services Rendered

Declaration by Service Recipient

% of the services being rendered to the real property identified above are directly connected with the construction of a new

building or a new addition that expands the cubic footage of an existing building or with the making of site improvements that put the

property affected to a new use. As defined in Conn. Agencies Regs. §12-407(2)(i)(I)-1(c)(1), these services are services rendered in the

construction of new real property and this percentage of the charges is not subject to 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.

Check one:

Owner

Name of Service Recipient

General Contractor

By:

Authorized Signature of Service Recipient

Title

Date

CERT-104 (BACK)

(Rev. 01/05)

Form Cert-104 - Services Certificate For New Construction Page 2