Contractor's Exempt Purchase Certificate
Document Title: CERT-141,  Contractor's Exempt Purchase Certificate
Department of Revenue Services
State of Connecticut
25 Sigourney Street Ste 2
Hartford CT 06106-5032

CERT-141

(Rev. 03/09)

Contractors Exempt Purchase Certicate
General Purpose: Contractors for the repair, alteration,
improvement, remodeling, or construction of real property use this
certicate to purchase materials and supplies to be installed or placed
in a project being performed under contract with an exempt entity.
The materials and supplies, including tangible personal property
that remains tangible personal property after its installation or
placement, must remain in the project after its completion. If the
tangible personal property is not used in the manner described above,
a contractor who claimed an exemption owes use tax on the total
price of the tangible personal property.
Name of exempt entity

Wherever the term contractor is used in this certicate, it includes
subcontractors of the contractor performing a contract with an
exempt entity.
Exempt entity means any person entitled to make purchases of
tangible personal property exempt from sales and use taxes under
the statutory authority listed in the instructions.

Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Address of project
Type of exempt entity (See instructions.)
Connecticut state government: Enter the exemption number. _________________________________

Connecticut municipality

Charitable or religious organization: Enter the exemption number if any. ______________________

Federal government

Other (Explain.) ____________________________________________________________________________________________________
Name of purchaser

Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Name of seller

Address

CT Tax Registration Number
(If none, explain.)

Federal Employer ID Number

Provide a written description of each item purchased. Attach additional sheets if necessary.

Check one box:

Blanket certicate

Certicate for one purchase only

Declaration by Purchaser: The item(s) described above are tangible personal property to be installed or placed in a project being performed
under contract with the exempt entity identied above and will remain in the project after its completion. I declare that the purchaser named
above is a contractor under contract with the exempt entity or a subcontractor of the contractor. I acknowledge that the purchaser will be
liable for Connecticut use tax, plus applicable penalty and interest as of the date of purchase, on the total purchase price of the property if
any of the requirements for the exemption are not present or are not met.
I declare under penalty of law that I have examined this 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 the Department of Revenue Services (DRS) is a ne of not more than $5,000 or imprisonment for not more than ve years, or both.

Name of purchaser
By:
Authorized signature



Title



Date

Extracted from PDF file ct-cert-141.pdf, last modified June 2007