Arizona Form 5005 - Transaction Privilege Tax Prime Contractor'S Certificate

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Arizona Department of Revenue

ARIZONA FORM

5005

Transaction Privilege Tax

Prime Contractor's Certificate

This Certificate is prescribed by the Department of Revenue pursuant to ARS § 42-1310.16 (E)

This Certificate shall be completed by the prime contractor and furnished to the subcontractor to fix the liability for the tax under the prime contracting

classification. The prime contractor and the subcontractor shall retain this Certificate. The Department of Revenue will disregard this Certificate if it is

not complete.

Prime Contractor's Information

Transaction Privilege License #:

Name:

Address:

Taxpayer ID #:

AZ Contractor License #:

Form of Business: Corporation

Partnership

Sole Proprietorship

Telephone No.:

Subcontractor's Information

Transaction Privilege License #:

Name:

Address:

Taxpayer ID #:

AZ Contractor License #:

Telephone No.:

* Single Project Information ( See Note )

Building Permit #:

Date:

Address:

Contract or Estimated Value:

Owner:

Commercial

Subdivision:

Book / Map / Parcel:

Residential

Log Number:

County:

* Blanket Certificate ( See Note )

From

Through

or until revoked

Specific Exceptions

Note:

If this certificate is for a single project, please complete the single project information block. If, on the other hand, this certificate is to cover all

projects between the prime contractor and subcontractor, ignore the first block and complete the "blanket certificate" block.

I understand that by executing this Certificate to the named subcontractor, I declare that I am the prime contractor on the

above mentioned contracting project(s) pursuant to ARS § 42-1310.16(E). Under law, by this declaration, I assume all

liability for any and all transaction privilege tax due on such contracting activity.

Further, if I am acting as an agent, I certify that I am authorized to execute this Certificate on behalf of the prime contractor named

above.

Signature

Print Name

Title

Date

If the information contained on this Certificate is incomplete or erroneous, the Department may disregard the Certificate.

Exact reproductions and photocopies of this certificate are acceptable for use.