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Form 5005 Fillable Prime Contractor's Certificate
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)DATE SIGNED FIELDS of the Signature section From: Through: box or the Until revoked box PROJECT DESCRIPTION must be supplied The (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) * ADDRESS: * NAME: * TRANSACTION PRIVILEGE LICENSE #: ** (For example; Building Permit # Address A Prime Contractor ADOR 60 2015 (4/02) ADOR 60 2015 (4/02) This Form Superseded All Other Form 5005 s and allows the Prime Contractor to exclude Specifi c and/or Legal Description) Arizona Department of Revenue ARIZONA FORM Arizona Department of Revenue disregarding the incomplete Arizona Department of Revenue Prime Contractor s Certifi cate Arizona statutes impose transaction privilege tax on entities ASSUMPTION OF LIABILITY AZ Contractor License #: B Subcontractor Blanket Certificate (check applicable box and fill in requested C Type of Certificate (check one and provide requested information) Certifi cate Certificate box of the Type of Certificate section must be checked checked the From: Through: dates must be completion of a contracting project intended to be within the contractor for that contracting project Obtaining a completed Contractor is assuming the prime contracting transaction privilege tax liability applicable to the above referenced project(s) contractor or has the burden of proving that it is not the prime date of the Blanket Certifi cate DATE SIGNED deemed incomplete by the Department of Revenue describing the excluded project(s) or the excluded Either the Single Project Certificate box or the Blanket engaged in the business of prime contracting If an entity Failure to complete these fields as specified may result in the for such project(s) However in some instances such entity GENERAL INSTRUCTIONS give a Certificate retroactive effect the Prime Contractor However the Certificate will only be given retroactive effect for I hereby certify that I have authority to sign this Certificate on behalf of Prime Contractor I understand that by excuting this Certifi cate Prime If a Certificate is signed subsequent to the commencement or If an entity is NOT LEGALLY the prime contractor for such If the Blanket Certificate box is checked either the If the Single Project Certificate box is checked the If the Specific Exceptions is checked details In most instances the entity assuming the prime contracting In order to ensure the effectiveness of the Certifi cate all In the event that the Blanket Certificate box is checked and incomplete or erroneous information) is not valid The Department may disregard this certificate pursuant to ARS 42 5075 E if the certificate is incomplete or erroneous If disregarded is the entity responsible for the tax location of the single project or the Certificate will be may not legally be the prime contractor for such project(s) meets the definition of the term contractor on a given project must be checked If the From: Through: box is must be completed must indicate next to the Until revoked box the effective of the entity shown as the Subcontractor on the Certifi cate if Period From: periods within 4 years of the execution date of the Certifi cate Prime Contractor s Certifi cate 5005 Prime Contractor s Certifi cate Instructions PRINT NAME PRIVILEGE LICENSE # fields of the Prime Contractor privilege tax as a taxable prime contractor PROJECT DESCRIPTION project description must be sufficient to identify the project(s) the Certificate will nevertheless be effective and projects or time periods from the Blanket Certifi cate provided The Specifi c Exceptions box is optional PURPOSE referenced in the Certificate will legally be the prime contractor required fields must be completed RETROACTIVE EFFECT retroactive effect to the Certificate for the intended project Revenue has the discretion to disregard the Certificate if it is revoked This certificate establishes responsibility for the transaction privilege tax; therefore it must be completed by the prime contractor assuming satisfies that burden of proof However the Department of scope of the Certificate the Department of Revenue will give section must be completed The prime contractor SIGNATURE Single Project Certificate Specifi c Exceptions: Subcontractor section must be complete Subdivision Book/Map/Parcel #s such Subcontractor IS LEGALLY the prime contractor Telephone #: that entity is liable for transaction privilege tax as a prime the contracting transaction privilege tax liability for the contracting project(s) The asterisked (*) items must be completed otherwise the certificate the entity accepting the certificate (subcontractor) will have the burden of proving (pursuant to ARS 42 5075 D) that it is not subject to transaction The NAME ADDRESS and TRANSACTION The NAME and ADDRESS fields of the The purpose of this form is to provide a subcontractor with the validation required for tax exemption of a particular project for a period of time or until The SIGNATURE TITLE PRINT NAME and the Until revoked option is selected thereunder in order to Through: time periods must be provided TITLE transaction privilege tax liability for the contracting project(s) Until revoked will subject such entity to the transaction privilege tax liability