Part II Retailer and Purchaser - Read instructions first, then complete Parts II, III, IV, and V.
Retailer Information
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Name of retailer _____________________________________________________________________ |
CT Tax Registration No. _____________________ |
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Street address |
_______________________________________________________________________ |
Date of sale ________________________________ |
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City or town, State, ZIP Code __________________________________________________________ |
Telephone No. _____________________________ |
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Purchaser Information |
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Name of purchaser ___________________________________________________________________ |
Daytime Telephone No. ______________________ |
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If an individual: |
If corporation, partnership, limited liability company, or other business entity: |
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Home address |
_________________________________________________ |
Business address |
_________________________________________________ |
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_________________________________________________ |
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_________________________________________________ |
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Name and |
_________________________________________________ |
Name and address _________________________________________________ |
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address of |
_________________________________________________ |
of partners, |
_________________________________________________ |
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employer |
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officers, members, |
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_________________________________________________ |
and operator(s) |
_________________________________________________ |
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_________________________________________________ |
of vessel |
_________________________________________________ |
Driver’s License Number State Expiration Date Driver’s License Number State Expiration Date (Attach copy of each out-of-state driver’s license. Use additional sheets if necessary for the names, addresses, and license numbers of additional drivers.)
Part III Vessel Identification Data
Year _______________ Make of vessel ________________________________________ Model ________________________________________
Length _____________ Hull ID number _____________________________ State of registration and number _______________________________
Location of slip or mooring _________________________________________________________________________________________________
Computation of Price |
Trade-In Data |
Gross sales price* __________________________________ |
Make _____________________________ Model __________________________ |
Trade-in allowance _________________________________ |
Type ________________________ Length ______________ Year ___________ |
Net sales price ____________________________________ |
State of registration and number __________________________________________ |
* Do not deduct manufacturer’s rebates from |
Hull ID number _______________________________________________________ |
the gross sales price. |
U.S.C.G. vessel documentation number ____________________________________ |
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Part IV Purchaser’s Declaration
Please initial:
______ I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, acknowledge that the retailer has explained to me the
meaning of a permanent place of abode as defined in Part I (or the requirements for business entities as described in Part I) and I declare that I do not maintain such a permanent place of abode in Connecticut.
I, the purchaser, or person authorized to sign on behalf of the purchaser named in Part II, declare that I purchased the vessel described in Part III from the retailer named in Part II. The purchaser is not a Connecticut resident and does not maintain a permanent place of abode in Connecticut, or the business entity meets the requirements described in Part I. The purchaser is a resident of (or the business entity is located in) the State of _______________________ . This vessel will
not be presented for registration, or is not required to be registered, with the Connecticut DMV. I declare under the penalty of false statement that I have examined this certificate 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 DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Signature of purchaser
or authorized person ________________________________________________ Date ________________________________________________________
If corporation, partnership, limited liability company, or other business entity:
Print name of purchaser
or authorized person ________________________________________________ Title _____________________________________ Date ____________
If jointly purchased,
signature of other purchaser __________________________________________ Print name of other purchaser ___________________________________
Part V |
Retailer’s Declaration |
Please initial: |
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I, an authorized agent of the retailer named in Part II, declare that I have explained to the purchaser that owning, leasing or otherwise maintaining |
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a permanent place of abode in Connecticut, even if it is not permanently occupied by the purchaser, subjects this purchase to Connecticut sales tax |
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and prohibits the use of this certificate. If the purchaser is a business entity, I have explained the exemption requirements for business entities set forth |
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in Part I, or if pertinent, I have explained the requirement for business entities to use this certificate as described in Part I. |
I, an authorized agent of the retailer named in Part II, declare under the penalty of false statement that I have examined this certificate 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 DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Print name of retailer’s authorized agent _________________________________________________________ Date _______________________________
Signature of retailer’s authorized agent ___________________________________________________________ Title _______________________________