Exempt Purchases by Qualifying Governmental Agencies
Document Title: CERT-134,  Exempt Purchases by Qualifying Governmental Agencies
Purchaser is:


United States

 of Connecticut
State
Name of agency

Name of agency (List exemption number, if any.)


Federal credit union


Connecticut municipality
Name of credit union

Town or district and agency

 entity exempted by Connecticut law
Other
Name of entity

Exempting Connecticut statute

Name of entity

Exempting federal statute

 entity exempted by federal law
Other
or check box if acknowledgment letter from DRS is attached.




Connecticut Development Authority

Agent of a qualifying governmental agency listed above (Attach documentation of appointment as agent.)
Name of agent:
Agents CT Tax Registration Number:

Agents Federal Employer ID Number:

Name of qualifying governmental agency:
Appointed agent for making the following types of purchases:

Address of purchaser:
Name of seller

Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number
Check one box:





Blanket certicate (CERT-134 may not be used as a blanket certicate for purchases of tangible personal property for resale at any one of ve
fundraising or social events per calendar year exempt under Conn. Gen. Stat. 12-412(94). See below.)
Certicate for one purchase only
Purchases that qualify for exemption under Conn. Gen. Stat. 12-412(94). Indicate the number of prior fundraising or social events during this
calendar year for which you claimed exemption under Conn. Gen. Stat. 12-412(94): _______________________

Check the appropriate box(es) and provide a written description of each item purchased:



Tangible personal property



Taxable services

Description:

Declaration by Purchaser
The item(s) described above are tangible personal property or services being purchased under the exemption provided in Conn. Gen. Stat. 12-412(1)(A)
or other applicable statute. The purchase of these items is exempt from sales and use taxes.
I declare under penalty of law that I have examined this certicate (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 to DRS is a ne of not more than $5,000 or
imprisonment for not more than ve years, or both.
Name of purchaser
By:
Signature of authorized person

Title

Date

If the purchaser is an entity exempted under Connecticut law other than Conn. Gen. Stat. 12-412(1)(A), I have entered the citation of the exempting law
above. If the purchaser is an entity exempted under federal law, I have entered the citation of the exempting law above, or, if there is no specic statutory
authority, I have attached a copy of the letter from DRS acknowledging the exempt status.
If the purchaser is an agent of a qualifying governmental agency, I have attached a copy of the document from the qualifying governmental agency expressly
designating the purchaser as agent.
CERT-134, Exempt Purchase by Qualifying Governmental Agencies (Rev. 07/09)





Connecticut Department of Revenue Services

Extracted from PDF file ct-cert-134.pdf, last modified November 1998