OMB No. 1545-0725

Expires 3-31-96

Fuel Bond Form 928

(Rev. March 1993)

(For use to post bond under section 4101) Department of the Treasury

Internal Revenue Service

Enter the effective date

of bond issued © Check the boxes that apply. This is an original bond strengthening bond superseding bond

Bonding

Telephone No.

( ) Bond is given by

Name

Address

as principal and

Name

Address

as surety. As principal and surety, we are obligated to the United States in the amount of

dollars ($ ). We also jointly and severally obligate our heirs, executors, administrators, successors, and assigns

for the payment of this amount.

The bond ensures payment of the tax imposed on fuel under section 4081 or 4091 of the Internal Revenue Code. The

conditions of the bond are that the principal and the surety agree that:

1. The principal will not attempt to defraud the United States of any tax under section 4081 or 4091;

2. The principal will file all returns and statements as required by law or regulations;

3. The principal will pay all taxes including any penalty and interest charges; and

4. The principal will comply with all other requirements of the law and regulations regarding tax under section 4081 or 4091.

The surety will be granted relief from liability under the bond at any time, provided the surety notifies the principal and the

district director of the Internal Revenue Service in writing at least 60 days before the date on which the surety wants to be

relieved of liability. If the notice is given by an agent of the surety, the notice must be accompanied by a power of attorney or a

verified statement that a power of attorney is on file with the district director.

If this notice is given, the principal’s rights under the bond will end on the date given in the notice, unless the notice is later

withdrawn in writing, or unless the principal’s rights are supported by other bonds. The surety will be relieved from any liability

for acts that occur after the date given in the notice but will remain liable for any unpaid tax and any penalties and interest

incurred by the principal before the bond was canceled, unless the principal pays the tax, penalties, and interest.

Signature

Under penalties of perjury, I declare that I have examined this form and any accompanying statements, and to the best of my knowledge and

belief, they are true, correct, and complete.

Signature of principal and surety

Signature of principal Name (please type or print) Date

Signature of surety Name (please type or print) Date

Approval by District Director

Bond approved Registration No.

Date

District Director: Send copy of approval form to principal shown above. District Director

For Paperwork Reduction Act Notice, see instructions. Form 928 (Rev. 3-93)

This bond is for: gasoline, diesel fuel, or aviation fuel excise tax.

Part III

Part I

Part II

Cat. No. 16984Z
Form 928 (Rev. 3-93) Page 2

Amount of Bond

We ask for the information on this form

to carry out the Internal Revenue laws of

the United States. You are required to

give us the information. We need it to

ensure that you are complying with

these laws and to allow us to figure and

collect the right amount of tax.

The liability stated on the bond is a

continuing one. It is not made for any

Gasoline.—Generally, the amount of

bond must equal the smaller of

$1 million or the tax (under section 4081)

that the principal is expected to incur

during an average month. However, the

bond may not be less than $2,000. If the

tax is not an even multiple of $100, the

bond must be increased to the next

higher multiple of $100. In the case of a

terminal operator, the bond must be the

smaller of $1 million or the tax (under

section 4081) on the expected volume of

gasoline that will flow through the

terminal operator’s equipment or facility

during an average month. Any bond

required for a terminal operator who

does not own any gasoline in the

terminal (for hire terminal operator) will

not be more than $500,000.

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is:

Recordkeeping 1 hr., 55 min. The district director may require a

strengthening or superseding bond if:

(1) it is necessary to ensure collection of

the tax imposed under section 4081, or

(2) the tax on the volume of gasoline

removed or sold in any month is more

than 120% of the existing bond if the

existing bond is less than $1 million, or

(3) the volume of taxable diesel fuel or

aviation fuel sold is greater than the

volume on which the existing bond is

based. See Regulations section

48.4101-2T(h) for more details on

strengthening and superseding bonds

for the gasoline excise tax.

Learning about the law

or the form 18 min.

Preparing, copying,

assembling, and sending

the form to the IRS 20 min.

If you have comments concerning the

accuracy of these time estimates or

suggestions for making this form more

simple, we would be happy to hear from

you. You can write to both the Internal

Revenue Service, Washington, DC

20224, Attention: IRS Reports Clearance

Officer, T:FP; and the Office of

Management and Budget, Paperwork

Reduction Project (1545-0725),

Washington, DC 20503. DO NOT file this

form with either of these offices. See

Where To File below.

Gasohol blenders.—Generally, the

amount of the bond must be the smaller

of $1 million or the rate of tax (under

section 4081(c)(2)) on the separation of

gasoline from the gasohol multiplied by

the number of gallons of gasoline the

blender expects to purchase at the

reduced tax rate during an average

month. If the tax is not an even multiple

of $100, the bond must be increased to

the next higher multiple of $100.

A “strengthening bond” is an

additional bond you give to increase the

amount of your existing bond. A

“superseding bond” is a new bond that

takes the place of an existing bond. If

you do not submit a strengthening or

superseding bond when required, your

registration may be suspended or

revoked.

General Instructions

Diesel and aviation fuel.—Generally,

the amount of the bond is the smaller of

$500,000 or the tax (under section 4091)

that would be due on the expected

volume of fuel (other than heating oil) to

be sold during an average month as if all

sales were fully taxable. If the tax is not

an even multiple of $100, the bond must

be increased to the next higher multiple

of $100.

Section references are to the Internal

Revenue Code unless otherwise noted.

Use this form to post bond required

under section 4101.

This form must be completed by any

person required by the district director

to post bond as a condition of

registration on Form 637, Application for

Registration, for purposes of the

gasoline, diesel fuel, or aviation fuel

excise tax.

Superseding bond for reduced

volume.—If the average monthly volume

of gasoline you removed or sold during

the most recent 12 consecutive months

is less than 80% of the volume used in

computing your existing bond, you may

request the district director’s permission

to give a superseding bond. If you are a

terminal operator, apply this test to the

average monthly volume of gasoline that

flowed through the terminal during the

most recent 12 consecutive months. If

you are a gasohol blender, apply the test

to the average monthly gallons of

gasoline purchased at the reduced tax

rate during the most recent 12

consecutive months.

Who May Sign as Principal

File Form 928 in duplicate with the

district director who required the posting

of the bond.

The surety on the bond must be listed in

the Department of the Treasury Circular

570 as an acceptable surety or reinsurer

on Federal bonds.

Paperwork Reducation Act

Notice

Purpose of Form

Who Must File

Where To File

Qualifying Sureties

Period of Bond

Strengthening or

Superseding Bond

The bond must be signed by: (1) the

individual, if the applicant is an

individual, (2) the president, vice

president, or other principal officer, if the

applicant is a corporation, (3) a

responsible and authorized member or

officer having knowledge of the

organization’s affairs, if the applicant is a

partnership or other unincorporated

organization, and (4) the fiduciary, if the

applicant is a trust or estate.

fixed period of time. If the quarterly

liability for excise tax that would be

imposed on gasoline, diesel fuel, or

aviation fuel is increased or decreased,

contact the district director immediately

after the quarter to see if a

strengthening or superseding bond is

necessary. The bond may also have to

be changed if there is a substantial

change in ownership or management of

the business.