Mailing Address: Post Office Box 1575, Mail Code 225 Colorado Springs, Colorado 80901-1575
TEL 719-385-5903 FAX 719-385-
5291 Email:
To City of Colorado Springs, do not use this form for Qualified Entity or COS Airport Projects
City Projects Only
Procedure for Contractor’s Certificate:
Please fill out this form completely. Unclear or improperly completed forms will be returned.
Information submitted on ST-17 COS INT 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 City of Colorado Springs. When applicable,
approved refunds are paid to the City, not to the contractor.
Contractor Name:
City of Colorado Springs
Account or License#:
The above listed contractor purchased the items listed on the attached documents from the vendors specified on those documents
and states that the following statements are true and correct.
All materials, supplies, tools, equipment and rentals were used on a project owned by the City of Colorado Springs.
Located at (job site location):
, Colorado Springs, Colorado.
The City of Colorado Springs contract number for this project is:
(3) Contractor paid all City of Colorado Springs Sales or Use Taxes (City Taxes) for the items purchased as specified in the
attached documents.
No materials were used on any other project or for any other purpose.
for sales tax and
for use tax
were paid to the vendors or to the City of Colorado Springs directly for those purchases
(see ST-17 COS INT Contractor Summary)
(6) 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.
(7) 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 Ordinance 2.7.604 Contractors, Owners or Lessees of Realty.
Contact Name/Title (Print):
Company Address:
Post Office Box or Street Address
City, State
Zip Code
Authorized Representative/Title (Print):
Authorized Representative Email Address:
Signature of Authorized Representative:
Revised 01/2020
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