16. Appendix
This appendix contains models of the certificates, waivers, reports, and statements discussed earlier under Fuel Taxes.
Model Certificate A
| 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
| FIRST TAXPAYER'S REPORT | |||||
| 1. | |||||
| First Taxpayer's name, address and employer identification 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 and that Registrant's registration has not | ||||
| 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 and enter: | ||||
| 1. | Invoice or delivery ticket number | |||
| 2. | (number of gallons) of (type of gasoline blendstocks) | |||
| If this is a certificate covering all purchases under a specified account or order number, check here and enter: | ||||
| 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 Excise Tax Regulations. | ||||
| 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 . Buyer's registration has not been revoked | ||||
| or suspended. | ||||
| The kerosene to which this certificate applies will be used by Buyer for a feedstock purpose. | ||||
| This certificate applies to percent of Buyer's purchases from (name, address, and employer | ||||
| identification number of seller) as follows (complete as applicable): | ||||
| 1.A single purchase on invoice or delivery ticket number . | ||||
| 2.All purchases between (effective date) and (expiration date) (period not to exceed | ||||
| one year after the effective date) under account or order number(s) . If this certificate applies only to Buyer's | ||||
| purchases for certain locations, check here and list the locations. | ||||
| 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 and enter: | |||||
| 1. Invoice or delivery ticket number | |||||
| 2. (number of MCFs) | |||||
| If this is a certificate covering all purchases under a specified account or order number, check here and enter: | |||||
| 1.Effective date | |||||
| 2.Expiration date | |||||
| (period not to exceed 1 year after the effective date) | |||||
| 3.Buyer's account or order number | |||||
| 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 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 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.) | |||
| Name, address, and employer identification number of position 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 on a farm for farming purposes; for use in foreign trade (reciprocal benefits required for foreign registered airlines); for use in certain helicopter and fixed-wing air ambulance uses; for use other than as a fuel in the propulsion engine of an aircraft; for the exclusive use of a qualified blood collector organization; for the exclusive use of a nonprofit educational organization; for the exclusive use of a state; for use in an aircraft owned by an aircraft museum; for use in military aircraft; or for use in commercial aviation (other than foreign trade). | |||
| 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 by the Internal Revenue Service. | |||
| This certificate applies to the following (complete as applicable): | |||
| This is a single purchase certificate: | |||
| 1. Invoice or delivery ticket number | |||
| 2. Number of gallons | |||
| This is a certificate covering all purchases under a specified account or order number: | |||
| 1.Effective date | |||
| 2.Expiration date (period not to exceed 1 year after the effective date) | |||
| 3.Buyer's account 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. Invoice or delivery ticket number | ||||||
| 2. Number of gallons | ||||||
| This is a waiver covering all purchases under a specified account or order number: | ||||||
| 1. Effective date | ||||||
| 2. Expiration date (period not to exceed 1 year after the effective date) | ||||||
| 3. Buyer's account number | ||||||
| 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 for tax. | ||||||
| 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 relates. | ||||||
| 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. | ||||||
| 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 Certificate M
| 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 vendor | |||
| The undersigned ultimate purchaser (“Buyer”) hereby certifies 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. Invoice or delivery ticket number | |||
| 2. Number of gallons | |||
| This is a certificate covering all purchases under a specified account or order number: | |||
| 1. Effective date | |||
| 2. Expiration date (period not to exceed 1 year after the effective date) | |||
| 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. | |||
| Buyer acknowledges that it has not and will not claim any credit or payment for the gasoline or aviation gasoline to which this certificate relates. | |||
| 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. | |||
| 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 N
| 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 vendor | |||
| The undersigned ultimate purchaser (“Buyer”) hereby certifies 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. Invoice or delivery ticket number | |||
| 2. Number of gallons | |||
| This is a waiver covering all purchases under a specified account or order number: | |||
| 1. Effective date | |||
| 2. Expiration date (period not to exceed 1 year after the effective date) | |||
| 3. Buyer's account number | |||
| Buyer will provide a new waiver to the vendor if any information 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 liable for tax. | |||
| Buyer understands that by signing this waiver, Buyer gives up its right to claim any credit or payment for the diesel fuel or kerosene used in intercity bus transportation. | |||
| Buyer acknowledges that it has not and will not claim any credit or payment for the diesel fuel or kerosene to which this waiver relates. | |||
| 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. | |||
| 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 Certificate O
| CERTIFICATE FOR BIODIESEL | ||||
| Certificate Identification Number: | ||||
| (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. | ||||