Arizona Department of Revenue
ARIZONA FORM
5005
Prime Contractor’s Certifi cate
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
revoked. This certifi cate establishes responsibility for the transaction privilege tax; therefore, it must be completed by the prime contractor assuming
the contracting transaction privilege tax liability for the contracting project(s). The asterisked (*) items must be completed, otherwise the certifi cate
is not valid. The Department may disregard this certifi cate pursuant to ARS § 42-5075.E if the certifi cate is incomplete or erroneous. If disregarded,
the entity accepting the certifi cate (subcontractor) will have the burden of proving (pursuant to ARS § 42-5075.D), that it is not subject to transaction
privilege tax as a taxable prime contractor.
A. Prime Contractor
* NAME:
* TRANSACTION PRIVILEGE LICENSE #:
* ADDRESS:
AZ Contractor License #:
Telephone #:
B. Subcontractor
* NAME:
* TRANSACTION PRIVILEGE LICENSE #:
* ADDRESS:
AZ Contractor License #:
Telephone #:
C. Type of Certifi cate (check one and provide requested information)
Single Project Certifi cate
Blanket Certifi cate (check applicable box and fi ll in requested
information).
PROJECT DESCRIPTION
OR
Period From:
Through:
Until revoked
Specifi c Exceptions:
** (For example; Building Permit #, Address,
Subdivision, Book/Map/Parcel #s,
and/or Legal Description)
I hereby certify that I have authority to sign this Certifi cate on behalf of Prime Contractor. I understand that by excuting this Certifi cate, Prime
Contractor is assuming the prime contracting transaction privilege tax liability applicable to the above referenced project(s).
SIGNATURE
PRINT NAME
TITLE
DATE SIGNED
ADOR 60-2015 (4/02)
This Form Superseded All Other Form 5005’s