STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
SALES & USE TAX RESALE CERTIFICATE
Address
Issued to (Seller)
is engaged as a registered
Name of Firm (Buyer)I certify that
) Wholesaler
(
(
(
(
(
) Retailer
Street Address or P.O. Box No.
) Manufacturer
) Lessor
) Other (specify)
State
City Zip
and is registered with the below listed states and cities within which your firm would deliver pur-
chases 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 the normal course of our business. We are in the
business of wholesaling, retailing, manufacturing, leasing (renting) the following:
State Registration
City or State
City or State
State Registration
or I.D. No.
or I.D. No.
State Registration
City or State
City or State
State Registration
or I.D. No.
Or I.D. No.
State Registration
City or State
State Registration
or I.D. No.
or I.D. 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 or use 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 billing. This certificate shall be part of
each order which we may hereafter give to you, unless otherwise specified, and shall be valid until
canceled 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
Date
Title
(Owner, Partner or Corporate Officer)
City or State
