Form 35-002a - Iowa Contractor'S Statement

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Iowa Department of Revenue
Iowa Contractor’s Statement
Name of government unit, private nonprofit education institution, nonprofit museum,
Contractor’s Name
business in economic development area, rural water district, or Habitat for Humanity
Address
Address
City, State, ZIP
City, State, ZIP
Iowa Sales or Use Tax Permit No.
FEIN
If contract is not directly with above name, who is your contract directly with?
1. Project Description:
2. Is your contract written? If so, date signed:
INCLUDE ONLY BUILDING MATERIALS THAT BECOME PART OF REAL PROPERTY. See instructions on reverse side.
A.
B.
C.
D.
E.
F.
G.
Name, City, and State of Material Supplier
Type of
Purchase
Amount of Iowa
Did supplier collect IA sales/
Amount of
County # where Iowa
Building Material
Price
sales/use tax
use tax? (yes/no) If no, who
Iowa local option tax
local option was paid
paid the tax/when?
1.
___________________________________________________
__________________
2.
___________________________________________________
__________________
3.
___________________________________________________
__________________
4.
___________________________________________________
__________________
5.
___________________________________________________
__________________
6.
___________________________________________________
__________________
7.
___________________________________________________
__________________
8.
___________________________________________________
__________________
TOTALS
Subscribed and sworn to by _____________________________ ,
I, “Contractor,” ______________________________________ state that this statement is made pursuant to section 423.4, Code of
Iowa, that all statements made herein are true and accurate to the best of my knowledge and belief; that all of the tangible personal
before me this _____ day of ____________________ ,20 ____ .
property described herein became an integral part of the project herein described, and sales or use tax was paid to Iowa as shown.
Notary Public in and for __________________ County of Iowa.
Name: __________________________________________ Title: ___________________________________
35-002a (07/01/13)

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