Mailing Address: Post Office Box 1575, Mail Code 225 Colorado Springs, Colorado 80901-1575
5-5903 FAX 719-385-5291 Email: firstname.lastname@example.org
CONTRACTOR’S CERTIFICATE AND ASSIGNMENT OF RIGHTS
To Qualified Entity, do not use this form for City or Airport Projects
Procedure for Contractor’s Certificate:
Please fill out this form completely. Unclear or improperly completed forms will be returned.
Information submitted on ST-16 COS QE must be original, typed or handwritten.
Must be signed by the contractor, subcontractor or an officer of the corporation including their title.
Contractor assigns any rights it may have to a refund of City Taxes paid to the Qualified Entity. When applicable, approved
refunds are paid to the qualified entity, not to the contractor.
Definition: “Qualified Entity” means a religious, charitable, and eleemosynary organization; the United States government, the
State of Colorado, its departments or institutions, and political subdivisions in the governmental capacity; and a school (other
than a school held or conducted for private or corporate profit) in the conduct of its educational functions and activities.
City of Colorado Springs
The above listed contractor purchased the materials listed on the attached documents from the vendors specified on those documents
and states that the following statements are true and correct.
All materials purchased were incorporated into a structure owned by (Qualified Entity):
Located at (job site location & phase):
, Colorado Springs, Colorado.
The structure was constructed pursuant to Building Permit No.:
, issued by the Pikes Peak Regional
Building Department (all copies attached.)
Contractor paid all City of Colorado Springs Sales or Use Taxes (City Taxes) for the materials purchased as specified in the
No materials were used on any other project or for any other purpose.
City of Colorado Springs taxes in the amount of
were paid to the vendors or to the City of Colorado Springs directly for those purchases (see ST-16 COS QE Contractor Summary)
Neither Contractor nor any person on behalf of the Contractor have applied for or received a refund of City of Colorado
Springs taxes paid either to/from the vendors or to/from the City of Colorado Springs.
Contractor will not claim or permit to be claimed on its behalf, that any City of Colorado Springs tax paid on those purchases
is exempt from City Tax.
I declare, under penalty of perjury, that this claim, and all accompanying schedules and statements, have been examined
by me and to the best of my knowledge and belief are true, correct, and made in good faith, pursuant to City of Colorado
Springs Sales and Use Tax Code and Colorado Springs Sales Tax Guide No. 06-101.
Contact Name/Title (Print):
Post Office Box or Street Address
Authorized Representative/Title (Print):
Authorized Representative Email Address:
Signature of Authorized Representative:
ST-16 COS QE
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