Notification Certificate of Taxable Fuel Registrant
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Name, address, and employer identification number of person receiving certificate
The undersigned taxable fuel 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registered by the Internal Revenue Service with registration number ______ and that Registrant's registration has not been revoked or suspended by the Internal Revenue Service.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 cost of prosecution.
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Signature and date signed
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Printed or typed name of person signing
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Title of person signing
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Name of registrant
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Employer identification number
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Address of registrant
26 C.F.R. §48.4081-5