After this certificate is completed and signed by both the customer and the contractor performing the capital improvement, it must be kept by the contractor. Copies of this certificate must be furnished to all subcontractors on the job and retained as part of their records.

Read this form completely before making any entries.

This certificate may not be used to purchase building materials exempt from tax.

To be completed by the customer
Describe capital improvement to be performed:

I certify that:

• I am the (mark an X in one)      owner        tenant of the real property identified on this form; and
• the work described above will result in a capital improvement to the real property as outlined in the instructions of this form; and
• this contract (mark an X in one)      includes        does not include the sale of any items that will not become a permanent part of the real property (for example, a free-standing microwave or washing machine).

I understand that:

• I will be responsible for any sales tax, interest, and penalty due on the contractor’s total charge for tangible personal property and for labor if it is determined that this work does not qualify as a capital improvement; and
• I will be required to pay the contractor the appropriate sales tax on tangible personal property (and any associated services) when the property installed by the contractor does not become a permanent part of the real property; and
• I will be subject to civil or criminal penalties (or both) under the Tax Law if I issue a false or fraudulent certificate.

To be completed by the contractor

I, the contractor, certify that I have entered into a contract to perform the work described by the customer named above, and that I accept this form in good faith. (A copy of the written contract, if any, is attached.) I understand that my failure to collect tax as a result of accepting an improperly completed certificate will make me personally liable for the tax otherwise due, plus penalties and interest.

This certificate is not valid unless all entries are completed.