Source: http://taxmap.ntis.gov/taxmap/archive2010/taxmap/pubs/p510-058.htm
Timestamp: 2014-03-11 09:28:29
Document Index: 309139722

Matched Legal Cases: ['§48', '§ 4081', '§ 4041', '§4041', '§ 6427', '§ 6416', '§ 6427']

taxmap/pubs/p510-058.htm#en_us_publink1000117365Chapter 17Appendix(p45)This appendix contains models of the certificates, waivers, reports,
and statements discussed in Part One.
STATEMENT OF SUBSEQUENT SELLER 1. Name, address, and employer identification number of seller
in subsequent sale 2. Name, address, and employer identification number of the
buyer in subsequent sale 3. Date and location of subsequent sale 4. Volume and type of taxable fuel sold The undersigned seller ("Seller") has received the copy of
the first taxpayer's report provided with this statement in connection with Seller's purchase of the taxable fuel described
in this statement. Under penalties of perjury, Seller declares that Seller has
examined this statement, including any accompanying schedules and statements, and, to the best of Seller's knowledge
and belief, they are true, correct and complete. Signature and date signed Printed or typed name of person signing this report Title Model Certificate B
number 2. Name, address, and employer identification number of the
buyer of the taxable fuel subject to tax 3. Date and location of removal, entry, or sale 4. Volume and type of taxable fuel removed, entered or sold 5.Check type of taxable event: Removal from refinery Entry into United States Bulk transfer from terminal by unregistered position holder Bulk transfer not received at an approved terminal Sale within the bulk transfer/terminal system Removal at the terminal rack Removal or sale by the blender 6. Amount of federal excise tax paid on account of the removal,
entry, or sale The undersigned taxpayer ("Taxpayer") has not received, and
will not claim, a credit with respect to, or a refund of, the tax on the taxable fuel to which this form relates. Under penalties of perjury, Taxpayer declares that Taxpayer
has examined this statement, including any accompanying schedules and statements, and to the best of Taxpayer's knowledge
and belief, they are true, correct and complete. Signature and date signed Printed or typed name of person signing this report Title Model Certificate C
NOTIFICATION CERTIFICATE OF TAXABLE FUEL REGISTRANT Name, address, and employer identification number of person
receiving certificate The undersigned taxable registrant ("Registrant") hereby
certifies under penalties of perjury that Registrant is registered by the Internal Revenue Service with registration number
been revoked or suspended by the Internal Revenue Service. Registrant understands that the fraudulent use of this certificate
may subject Registrant and all parties making such fraudulent use of this certificate to a fine or imprisonment,
or both, together with the costs of prosecution. Signature and date signed Printed or typed name of person signing Title of person signing Name of Registrant Employer identification number Address of Registrant Model Certificate D
CERTIFICATE OF PERSON BUYING GASOLINE BLENDSTOCKS FOR USE
OTHER THAN IN THE PRODUCTION OF FINISHED GASOLINE (To support tax-free sales (other than LUST) under section
4081 of the Internal Revenue Code.) Name, address, and employer identification number of seller The undersigned buyer ("Buyer") hereby certifies the following
under penalties of perjury: The gasoline blendstocks to which this certificate relates
will not be used to produce finished gasoline. This certificate applies to the following (complete as applicable): If this is a single purchase certificate, check here
If this is a certificate covering all purchases under a specified
account or order number, check here
1.Effective date 2.Expiration date (period not to exceed 1 year after the effective date) 3.Type (or types) of gasoline blendstocks 4.Buyer's account or order number Buyer will not claim a credit or refund under section 6427(h)
of the Internal Revenue Code for any gasoline blendstocks covered by this certificate. Buyer will provide a new certificate to the seller if any
information in this certificate changes. If Buyer resells the gasoline blendstocks to which this certificate
relates, Buyer will be liable for tax unless Buyer obtains a
certificate from the purchaser stating that the gasoline
blendstocks will not be used to produce finished gasoline and otherwise complies
with the conditions of §48.4081-4(b)(3) of the Manufacturers and Retailers
Buyer understands that if Buyer violates the terms of this
certificate, the Internal Revenue Service may withdraw Buyer's right to provide a certificate. Buyer has not been notified by the Internal Revenue Service
that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified
Buyer that the right to provide a certificate has been withdrawn from a
purchaser to which Buyer sells gasoline blendstocks tax free.
Buyer understands that the fraudulent use of this certificate
may subject Buyer and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together
with the costs of prosecution. Signature and date signed Printed or typed name of person signing Title of person signing Name of Buyer Employer identification number Address of Buyer Model Certificate G
CERTIFICATE OF REGISTERED FEEDSTOCK USER (To support tax-free removals and entries (other than LUST)
of kerosene under section 4082 of the Internal Revenue Code.) (Buyer) certifies the following under penalties of perjury: Name of buyer Buyer is a registered feedstock user with registration number
or suspended. The kerosene to which this certificate applies will be used
by Buyer for a feedstock purpose. This certificate applies to
applicable): 1. A single purchase on invoice or delivery ticket
one year after the effective date) under account or order
If Buyer sells the kerosene to which this certificate relates,
Buyer will be liable for tax on that sale. Buyer will provide a new certificate to the seller if any
information in this certificate changes. If Buyer violates the terms of this certificate, the Internal
Revenue Service may revoke the Buyer's registration. Buyer understands that the fraudulent use of this certificate
may subject Buyer and all parties making any fraudulent use of
this certificate to a fine or imprisonment, or both, together
with the costs of prosecution. Printed or typed name of person signing Title of person signing Employer identification number Address of Buyer Signature and date signed Model Certificate J
CERTIFICATE OF PERSON BUYING COMPRESSED NATURAL GAS (CNG)
FOR A NONTAXABLE USE (To support tax-free sales of CNG under section 4041 of the
Internal Revenue Code.) Name, address, and employer identification number of seller ("Buyer") certifies the following under penalties of perjury: Name of buyer The CNG to which this certificate relates will be used in
a nontaxable use. This certificate applies to the following (complete as applicable): If this is a single purchase certificate, check here
Buyer will not claim a credit or refund under section 6427
of the Internal Revenue Code for any CNG to which this certificate relates.
Buyer will provide a new certificate to the seller if any
information in this certificate changes. Buyer understands that if Buyer violates the terms of this
Buyer that the right to provide a certificate has been withdrawn from a purchaser to which Buyer sells CNG tax free. Buyer understands that the fraudulent use of this certificate
may subject Buyer and all parties making any fraudulent use of this certificate to a fine or imprisonment, or both, together
with the costs of prosecution. Printed or typed name of person signing Title of person signing Employer identification number Address of Buyer Signature and date signed Model Certificate K
CERTIFICATE OF PERSON BUYING KEROSENE FOR USE IN AVIATION
FOR COMMERCIAL AVIATION OR NONTAXABLE USE (To support operator liability for tax on removals of kerosene
for use in aviation directly into the fuel tank of an aircraft in commercial
aviation pursuant to § 4081 of the Internal Revenue Code or to support a
tax rate of zero under § 4041(c) pursuant to §§4041(c) and 4082.)
holder The undersigned aircraft operator ("Buyer") hereby certifies
the following under the penalties of perjury: The kerosene for use in aviation to which this certificate
relates is purchased (check one):
for use in certain helicopter and fixed-wing air ambulance
With respect to kerosene for use in aviation purchased after
June 30, 2005, for use in commercial aviation (other than foreign trade), Buyer's registration number is . Buyer's registration has not been suspended or revoked
This certificate applies to the following (complete as applicable): This is a single purchase certificate: 1. Invoice or delivery ticket number
Buyer agrees to provide the person liable for tax with a
new certificate if any information in this certificate changes. If the kerosene for use in aviation to which this certificate
relates is being bought for use in commercial aviation (other than foreign trade), Buyer is liable for tax on its
use of the fuel and will pay that tax to the government. If Buyer sells or uses the kerosene for use in aviation to
which this certificate relates for a use other than the use stated above, Buyer will be liable for tax. Buyer understands that it must be prepared to establish by
satisfactory evidence the purpose for which the fuel purchased under this certificate was used. Buyer has not been notified by the Internal Revenue Service
that its right to provide a certificate has been withdrawn. If Buyer violates the terms of this certificate, the Internal
Revenue Service may withdraw Buyer's right to provide a certificate. The fraudulent use of this certificate may subject Buyer
and all parties making any fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution. Printed or typed name of person signing Title of person signing Name of Buyer Employer identification number Address of Buyer Signature and date signed Model Waiver L
WAIVER FOR USE BY ULTIMATE PURCHASERS OF KEROSENE FOR CERTAIN
USES IN AVIATION(To support vendor's claim for a credit or payment under
§ 6427(l)(4)(C)(i) of the Internal Revenue Code.) Name, Address, and Employer Identification Number of Ultimate
Vendor The undersigned ultimate purchaser ("Buyer") hereby certifies
the following under penalties of perjury: A.The kerosene to which this waiver relates is purchased for
— (check one): 1.□Use on a farm for farming purposes, 2.□Use in foreign trade (reciprocal benefits required for foreign
registered airlines), 3.□Use in certain helicopter and fixed-wing air ambulance uses, 4.□The exclusive use of a qualified blood collector organization, 5.□The exclusive use of a nonprofit educational organization, 6.□Use in an aircraft owned by an aircraft museum, 7.□Use in military aircraft, or 8.□Use in commercial aviation (other than foreign trade). B.This waiver applies to the following (complete as applicable): This is a single purchase waiver: 1.
This is a waiver covering all purchases under a specified
account or order number: 1. Effective date
Buyer will provide a new waiver to the vendor if any information
in this waiver changes. If Buyer uses the kerosene for use in aviation to which this
waiver relates for a use other than the use stated above, Buyer will be liable
Buyer understands that by signing this waiver, Buyer gives
up its right to claim any credit or payment for the kerosene for use in aviation
used in a nontaxable use.
Buyer acknowledges that it has not and will not claim any
credit or payment for the kerosene for use in aviation to which this waiver
Buyer understands that the fraudulent use of this waiver
may subject Buyer and all parties making such fraudulent use of this waiver to a
fine or imprisonment, or both, together with the costs of prosecution.
CERTIFICATE FOR STATE USE OR NONPROFIT EDUCATIONAL ORGANIZATION USE (To support vendor's claim for a credit or payment under
§ 6416(a)(4) of the Internal Revenue Code.) Name, address, and employer identification number of ultimate
the following under the penalties of perjury: Buyer will use the gasoline or aviation gasoline to which
this certificate relates (check one): For the exclusive use of a state or local government; or For the exclusive use of a nonprofit educational organization. This certificate applies to the following (complete as applicable): This is a single purchase certificate: 1.
This is a certificate covering all purchases under a specified
3. Buyer's account number Buyer will provide a new certificate to the vendor if any
information in this certificate changes. Buyer understands that by signing this certificate, Buyer
gives up its right to claim any credit or payment for the gasoline or aviation
gasoline to which this certificate relates.
credit or payment for the gasoline or aviation gasoline to which this
may subject Buyer and all parties making such fraudulent use of this certificate
WAIVER FOR USE BY ULTIMATE PURCHASERS OF DIESEL FUEL OR KEROSENE USED IN INTERCITY BUS TRANSPORTATION (To support vendor's claim for a credit or payment under
§ 6427 of the Internal Revenue Code.) Name, address, and employer identification number of ultimate
the following under the penalties of perjury: The diesel fuel or kerosene to which this waiver relates
is purchased for use in intercity bus transportation. This waiver applies to the following (complete as applicable): This is a single purchase waiver: 1.
in this waiver changes. If Buyer uses the diesel fuel or kerosene to which this waiver
relates for a use other than in intercity bus transportation, Buyer will be
up its right to claim any credit or payment for the diesel fuel or kerosene used
in intercity bus transportation.
credit or payment for the diesel fuel or kerosene to which this waiver relates.
(To support a claim related to biodiesel or a biodiesel mixture
under section 6426 of the Internal Revenue Code.) The undersigned biodiesel producer ("Producer") hereby certifies
the following under penalties of perjury: 1. Producer's name, address, and employer identification number
(EIN) 2. Name, address, and EIN of person buying the biodiesel from
Producer 3. Date and location of sale to buyer 4.This certificate applies to
5.Producer certifies that the biodiesel to which this certificate
relates is: %
Biodiesel other than agri-biodiesel This certificate applies to the following sale: Invoice or delivery ticket number Total number of gallons of biodiesel sold under that invoice
or delivery ticket number (including biodiesel not covered by this certificate)
Total number of certificates issued for that invoice or delivery
ticket number 6. Name, address, and employer identification number of reseller
to whom certificate is issued (only in the case of certificates reissued to a
reseller after the return of the original certificate)
Producer is registered as a biodiesel producer with registration
.Producer's registration has not been suspended or revoked
Producer certifies that the biodiesel to which this certificate
relates in monoalkyl esters of long chain fatty acids derived from plant or
animal matter that meets the requirements of the American Society of Testing and
Materials D6751 and the registration requirements for fuels and fuel additives
established by EPA under section 211 of the Clean Air Act (42 U.S.C. 7545).
Producer understands that the fraudulent use of this certificate
may subject Producer and all parties making any fraudulent use of this
certificate to a fine or imprisonment, or both, together with the costs of
CERTIFICATE OF STATE USE(To support vendor's claim for credit or payment under section
6427 of the Internal Revenue Code.) Name, Address, and Employer Identification Number of Vendor The undersigned buyer ("Buyer") hereby certifies the following
under penalties of perjury: A.Buyer will use the diesel fuel or kerosene to which this
certificate relates for the exclusive use of a state or local government, or the
B.This certificate applies to the following (complete as applicable): 1. If this is a single purchase certificate, check here □
and enter: a.Invoice or delivery ticket number
2. If this is a certificate covering all purchases under a specified
account or order number, check here □
▪Buyer will provide a new certificate to the vendor if any
information in this certificate changes. ▪If Buyer uses the diesel fuel or kerosene to which this certificate
relates for a purpose other than stated in the certificate, Buyer will be liable
for any tax.
▪Buyer acknowledges that it has not and will not claim any
credit or payment for the diesel fuel or kerosene to which this certificate
▪Buyer understands that the fraudulent use of this certificate
CERTIFICATE OF ULTIMATE PURCHASER OF KEROSENE FOR USE IN
NONEXEMPT, NONCOMMERCIAL AVIATION(To support vendor's claim for credit or payment under section
6427(l)(4)(C)(ii) of the Internal Revenue Code.) Name, Address, and Employer Identification Number of Ultimate
the following under penalties of perjury: A.The kerosene to which this certificate relates is purchased
for a nonexempt use in noncommercial aviation. B.This certificate applies to the following (complete as applicable): 1. If this is a single purchase certificate, check here □
2. This is a certificate covering all purchases under a specified
account or order number: a.Effective date
c.Buyer's account number ▪Buyer will provide a new certificate to the vendor if any
information in this certificate changes. ▪If Buyer uses the kerosene to which this certificate relates
for a use other than the nontaxable use stated above, Buyer will be liable for
CERTIFICATE OF BUYER OF TAXABLE FUEL FOR USE BY A STATE OR
NONPROFIT EDUCATIONAL ORGANIZATION(To support credit card issuer's claim for credit, refund,
or payment under section 6416(a)(4)(B) or section 6427(l)(5)(D) of the Internal
Name, Address, and Employer Identification Number of Credit
Card Issuer. The undersigned ultimate purchaser ("Buyer") hereby certifies
the following under penalties of perjury: A.Buyer will use the taxable fuel to which this certificate
relates for the exclusive use of a state; or B.Buyer will use the gasoline to which this certificate relates
for the exclusive use of a nonprofit educational organization. C.This certificate applies to all purchases made with the credit
card identified below during the period specified: a.Effective date of certificate b.Expiration date of certificate
c.Buyer's account number ▪Buyer will provide a new certificate to the credit card issuer
if any information in this certificate changes. ▪Buyer understands that by signing this certificate, Buyer
gives up its right to claim a credit or payment for the taxable fuel purchased
with the credit card to which this certificate relates.
credit or payment for the taxable fuel purchased with the credit card to which
this certificate relates.
STATEMENT OF BIODIESEL RESELLER (To support a claim related to biodiesel or a biodiesel mixture
under section 6426 of the Internal Revenue Code.) The undersigned biodiesel producer ("Reseller") hereby certifies
the following under penalties of perjury: 1. Reseller's name, address, and employer identification number
(EIN) 2. Name, address, and EIN of Reseller's buyer 3. Date and location of sale to buyer 4.Volume of biodiesel sold 5.Certificate Identification Number on the Certificate for
Biodiesel Reseller has bought the biodiesel described in the accompanying
Certificate for Biodiesel and Reseller has no reason to believe that any
Reseller has not been notified by the Internal Revenue Service
that its right to provide a certificate or statement has been withdrawn.
Reseller understands that the fraudulent use of this statement
may subject Reseller and all parties making any fraudulent use of this statement