36C26319B0002-0003004.pdf

Iowa Department of Revenue https://tax.iowa.gov Iowa Contractor’s Statement

35-002a (07/21/15)

Contractor’s Name:

Address:

City, State, ZIP:

Iowa Sales or Use Tax Permit Number (if any):

SSN or FEIN:

Project Description:

Is your contract written? Yes ☐, No ☐ If yes, date signed: / /

Name of government unit, private nonprofit education institution, nonprofit museum, business in economic development area, rural water district, or

Habitat for Humanity:

Address:

City, State, ZIP:

If contract is not directly with above name, who is your contract directly with?

INCLUDE ONLY BUILDING MATERIALS THAT BECOME PART OF REAL PROPERTY. See instructions on reverse side.

Subscribed and sworn to by before me on this day of 20

Notary Public in and for County of Iowa.

I, “Contractor”, state that his statement is made pursuant to section 423.4, Code of Iowa, that all statements made herein, are true and accurate to the best of my knowledge and belief; that all of the tangible personal property described herein became an integral part of the project herein described, and sales or use tax was paid to Iowa as shown.

Signature: Title:

A

Name, City, and State of Material Supplier

B

Type of Building Material

C

Purchase Price

D

Amount of Iowa

Sales/Use Tax

E Did Supplier Collect Iowa Sales/ Use Tax? (Yes/No)

If “No”, Who Paid the Tax? When?

F

Amount of Iowa Local

Option Tax

G

County Number

Where Iowa Local Option

Was Paid

Total (provide the totals for columns C, D and F)

Iowa Contractor’s Statement, page 2

35-002b (07/21/15)

Instructions

This Contractor’s Statement must be prepared and sworn to by each general contractor, special contractor, or subcontractor who fulfills a contract or subcontract pertaining to a project that is sponsored by agencies or instrumentalities of the federal, state, county, municipal governments, private nonprofit educational institutions, nonprofit museums, businesses in economic development areas, rural water districts, or Habitat for Humanity.

Upon completion of the contract, this form must be presented to that sponsor so they may file for a tax refund in accordance with section 423.4, Iowa Code, as amended.

The Iowa Department of Revenue may require additional information.

Contractor:

Forward this statement to the sponsor (governmental unit, private nonprofit educational institution, nonprofit museum, business in economic development area, rural water district, or Habitat for Humanity). Do not send it to the Iowa Department of Revenue.

Sponsor:

This statement must be attached to the Construction Contract Claim for

Refund (35-003). Both forms must be filed before the Department can process your claim. File using this form. Substitutes or photocopies will not be accepted. The claim for refund must be filed within one year of the final settlement date of the contract.

Columns A through E must be completed. If local option sales tax was paid on the purchase price, complete columns A through G.

A. Name, City, and State of Material Supplier

Enter “out of stock” or “inventory in column A for materials that the contractor has manufactured or has in inventory, making the contractor the material supplier.

B. Type of Building Material

Be specific. Only the items that become an integral part of the structure should be listed. The following is a nonexclusive list of items that should not be included on this form: Equipment rental, machinery, equipment, tools, utilities, warning lights, barricades, portable toilets, forms, stakes, scaffolding, dynamite, lodging, fuel, and labor.

C. Purchase Price

Cost of material shown in column B. Do not include transportation charges, delivery charges, or hauling charges. Do not include sales/use or local option sales tax in this column.

D. Amount of Iowa Sales / Use Tax Compute on the purchase price recorded in column C. Do not include local option sales tax in column D. Invoices may be requested to verify amounts.

E. Did Supplier Collect Iowa Sales / Use Tax?

If the answer is “No”, include who paid the tax, the date the tax was paid, and the Iowa permit number under which it was remitted. If no Iowa tax was paid, please explain why not and/or to which state the tax was paid.

F. Amount of Iowa Local Option Tax

In addition to the state sales and use tax in column D, there may be purchases that were subject to local option tax. Enter the amount of local option tax in column F. Do not include local option tax in column D entry.

G. County Number Where Iowa Local Option Was Paid

Number of the county for which local option sales tax was paid. See the list below.

IOWA COUNTIES AND COUNTY NUMBERS

County Numbers

01 to 25

County Numbers 26 to 50

County Numbers 51 to 75

County Numbers 76 to 99

01-ADAIR 26-DAVIS 51-JEFFERSON 76-POCAHONTAS

02-ADAMS 27-DECATUR 52-JOHNSON 77-POLK

03-ALLAMAKEE 28-DELAWARE 53-JONES 78-POTTAWATTAMIE

04-APPANOOSE 29-DES MOINES 54-KEOKUK 79-POWESHIEK

05-AUDUBON 30-DICKINSON 55-KOSSUTH 80-RINGGOLD

06-BENTON 31-DUBUQUE 56-LEE 81-SAC

07-BLACK HAWK 32-EMMET 57-LINN 82-SCOTT

08-BOONE 33-FAYETTE 58-LOUISA 83-SHELBY

09-BREMER 34-FLOYD 59-LUCAS 84-SIOUX

10-BUCHANAN 35-FRANKLIN 60-LYON 85-STORY

11-BUENA VISTA 36-FREMONT 61-MADISON 86-TAMA

12-BUTLER 37-GREENE 62-MAHASKA 87-TAYLOR

13-CALHOUN 38-GRUNDY 63-MARION 88-UNION

14-CARROLL 39-GUTHRIE 64-MARSHALL 89-VAN BUREN

15-CASS 40-HAMILTON 65-MILLS 90-WAPELLO

16-CEDAR 41-HANCOCK 66-MITCHELL 91-WARREN

17-CERRO GORDO 42-HARDIN 67-MONONA 92-WASHINTON

18-CHEROKEE 43-HARRISON 68-MONROE 93-WAYNE

19-CHICKASAW 44-HENRY 69-MONTGOMERY 94-WEBSTER

20-CLARKE 45-HOWARD 70-MUSCATINE 95-WINNEBAGO

21-CLAY 46-HUMBOLDT 71-O’BRIEN 96-WINNESHIEK

22-CLAYTON 47-IDA 72-OSCEOLA 97-WOODBURY

23-CLINTON 48-IOWA 73-PAGE 98-WORTH

24-CRAWFORD 49-JACKSON 74-PALO ALTO 99-WRIGHT

25-DALLAS 50-JASPER 75-PLYMOUTH