Certificate of Person Buying Gasoline Blendstocks for use Other Than in the Production of Finished Gasoline
(To support tax-free sales 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 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Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified Buyer that the right to provide a certificate has been withdrawn from a purchaser to which Buyer sells gasoline blendstocks tax free.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
26 C.F.R. §48.4081-4