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Form Cert-102 - Certified Rehabilitation Certificate For Certified Historic Structures 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 Real Property

General Description of Services Rendered

Declaration by Service Provider

The real property identified in this certificate is a certified historic structure as defined in Internal Revenue Code §47(c)(3)(A).

The structure is being substantially rehabilitated as defined in Internal Revenue Code §47(c)(1)(C).

The rehabilitation will be a certified rehabilitation as defined in Internal Revenue Code §47(c)(2)(C).

% of the services being rendered to the real property identified on the front of this certificate are directly connected with its

substantial and certified rehabilitation. As defined in Conn. Agencies Regs. §12-407(2)(i)(I)-1(c)(1), these services are treated as 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

General Contractor

Name of Service Recipient

Subcontractor

By:

Authorized Signature of Service Recipient

Title

Date

CERT-102 (Back)

(Revised 01/05)

Form Cert-102 - Certified Rehabilitation Certificate For Certified Historic Structures Page 2