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 (the "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, the 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
Statement of Subsequent Seller
1. _______________________________
_______________________________
Name, address, and employer identification number of seller in subsequent sale
2. _______________________________
_______________________________
Name, address, and employer identification number of buyer in subsequent sale
3. _______________________________
Date and location of subsequent sale
4. _______________________________
Volume and type of taxable fuel sold
The undersigned seller (the "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 statement
_______________________________
Title
26 C.F.R. §48.4081-7