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IRS.gov Website
Publication 510
taxmap/pubs/p510-056.htm#en_us_publink1000117365

Chapter 18
Appendix(p43)

This appendix contains models of the certificates, waivers, reports, and statements discussed in Part One.

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.         (Gasoline gallon equivalents)  
  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. 
  
 Name, address, and EIN of person buying the biodiesel from Producer  
3. 
 Date and location of sale to buyer 
4.This certificate applies to      gallons of biodiesel.  
5.Producer certifies that the biodiesel to which this certificate relates is: 
    % Agri-biodiesel (derived solely from virgin oils) 
    % 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)  
7.      Original Certificate Identification Number (only in the case of certificates reissued to a reseller after return of the original certificate).  
  Producer is registered as a biodiesel producer with registration number      .
Producer's registration has not been suspended or revoked by the Internal Revenue Service.
 
  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 prosecution.  
  
 Printed or typed name of person signing this certificate 
  
 Title of person signing 
  
 Signature and date signed 

Model Certificate P

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 District of Columbia.  
 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                                
    b.Number of gallons                                        
  2. If this is a certificate covering all purchases under a specified account or order number, check here □
and enter:
 
    a.Effective date                                         
    b.Expiration date                                       
(period not to exceed 1 year after effective date)
 
    c.Buyer's account or order number                                 
 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 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 Certificate Q

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 Vendor 
 The undersigned ultimate purchaser ("Buyer") hereby certifies 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 □ and enter: 
    a.Invoice or delivery ticket number  
    b.Number of gallons  
  2. This is a certificate covering all purchases under a specified account or order number: 
    a.Effective date  
    b.Expiration date
(period not to exceed 1 year after 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 tax.  
 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 Certificate R

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 Revenue Code.)
  
  
 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
(period not to exceed 2 years after effective date)
 
    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.  
 Buyer acknowledges that it has not and will not claim any credit or payment for the taxable fuel purchased with the credit card 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 Statement S

 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 information in the certificate is false.  
  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 to a fine or imprisonment, or both, together with the costs of prosecution.  
  
 Printed or typed name of person signing this certificate 
  
 Title of person signing 
  
 Signature and date signed