27-008 Sewer Lift Station Replacement

CITY of HICKORY
Intent to Award
Project Title: Bid Number:
SALES TAX CERTIFICATION
INSTRUCTIONS:
1. Save blank copies of this certification if awarded the project; Certification to be
completed and submitted with each invoice sent to the City
2. All completed certifications should be notarized at the time of completion; if there
is no sales tax to report, then write "Labor Only" across the form and submit
3. All columns should be totaled at the bottom of the form
4. Incomplete forms will not be accepted and contract payment may be delayed.
5. It is very important that the sales tax is broken down between the applicable state
and county portions; and that the name of the county (in which point of delivery
occurred) be stated correctly.
DESCRIPTION OF COLUMNS:
Vendor Name of the company to which the sales tax was actually paid
Address Address of the company to which the sales tax was paid
Invoice Invoice Number
Date Date of the Invoice
Net Amount Net amount of the invoice (excluding tax)
State Tax Amount of sales tax for North Carolina
County Tax Amount of sales tax for the county
Special Tax Amount of special sales tax paid to counties
(only Mecklenburg, Durham, & Orange counties 0.5%)
County Name The name of the county which the goods changed hands
For questions please call 828-323-7470
SALES TAX CERTIFICATION FORM ON NEXT PAGE

CITY of HICKORY
Intent to Award
Project Title: Bid Number:
SALES TAX CERTIFICATION FORM
Company Name ____________________ Period Covered ____________________
0.5% Other:
Net Invoice 4.75% 2.25% 2.25%
Vendor Address Invoice # Date Special County Name
Amount State Tax Catawba TaxAlexander Tax
Tax
TOTALS:
_______________________________ being duly sworn, certifies that the foregoing statement of sales
tax paid in connection with the referenced contract does not contain sales or use taxes paid on purchases
of tangible personal property purchased by such contractors for use in performing the contract which
does not annex to, affix to, or in some manner become a part of the building or structure being erected,
altered, or repaired for the governmental entities as defined by G.S. 105-164.14( c), and is to the best of
his/her belief true and correct.
Sworn to and subscribed before me this __ day of , 20 ___.

Signature
__________________________________________
Printed Name
_____
Title
_____
Date
SEAL:
Notary Public
______________________________________
Date