STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
NINETY-TWO FARMINGTON AVE., HARTFORD, CONECTICUT 06105
AN EQUAL OPPORTUNITY EMPLOYER
SALES AND USE TAX RESALE CERTIFICATE
Issued to (Seller) ________________________________________________________________________________________
Address _______________________________________________________________________________________________
I certify that ___________________________________________________________________(Buyer) is engaged as a registered
(_) Wholesaler (_) Retailer (_) Manufacturer (_) Lessor (_) Other (Please Specify)_______________________________________
Street Address or P.O. Box No. ____________________________________________________________________________
City _____________________________________ State __________________________ Zip Code _____________________
and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases
are for wholesale, resale, ingredients or components of a new product to be resold, leased, or rented in thenormal course of our business.
We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following :
_______________________________________________________________________________________________________
City or State : _____________________________________City or State : ____________________________________________
State Registration or ID No. :_________________________ State Registration or ID No. : _________________________________
City or State : _____________________________________City or State : ____________________________________________
State Registration or ID No. :_________________________ State Registration or ID No. : _________________________________
City or State : _____________________________________City or State : ____________________________________________
State Registration or ID No. :_________________________ State Registration or ID No. : _________________________________
I further certify that if any property so purchased tax free is used or consumed by the firm as to make it subject to a sales tax we will pay
the tax due direct to the proper taxing authority when state law so provides or inform the seller for added tax billings. This certificate shall
be par of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until cancelled by us in writing or
revoked by the city or state.
General Description of products to be purchased from the seller:______________________________________________________
______________________________________________________________________________________________________
I declare under the penalties of false statement that this certificate has been examined by me and to the best of my knowledge and belief is
a true, correct and complete certificate.
Authorized Signature __________________________________ (Owner, Partner or Corporate Officer)
Title_______________________________________________
Date ______________________________________________