Exemption Certificate
(For use by persons who purchase tread rubber from the manufacturer, producer, or importer thereof for use otherwise than in recapping or retreading tires of the type used on highway vehicles (section 4073(c) of the Internal Revenue Code).)
(Date) ________________________, 19____
I, the undersigned, certify that I am the purchaser, or the (Title) ______ of (Name of purchaser if other than the undersigned) __________ who is the purchaser of: ____ The tread rubber specified in the accompanying order or contract, or ____ All tread rubber specified in contracts or orders entered into or placed with (Name of seller) ______ for the period commencing ______ and ending ______ (period not to exceed 12 calendar quarters), and that such tread rubber will not be used in the recapping or retreading of tires of the type used on highway vehicles, but will be used for the following purposes:
_______________________________
_______________________________
_______________________________
The undersigned understands that if the tread rubber is used for the recapping or retreading of tires of the type used on highway vehicles, or is sold or otherwise disposed of, such fact must be promptly reported to the manufacturer. The undersigned also understands that the fraudulent use of this certificate for the purpose of securing this exemption will subject the undersigned or any other party making such fraudulent use to a fine of not more than $10,000, or to imprisonment for not more than 5 years, or both, together with costs of prosecution. The purchaser also understands that the purchaser must be prepared to establish by satisfactory evidence the purpose for which the tread rubber was used.
(Signature) _______________________________
(Address)_______________________________
26 C.F.R. §48.4073-3
Secs. 4071(b), 4071(c), 4073(c), and 7805, Internal Revenue Code of 1954. (80 Stat. 331, 26 U.S.C. 4071(b) ; 68A Stat. 482, 26 U.S.C. 4071(c) ; 70 Stat. 389, 26 U.S.C. 4073(c) ; 68A Stat. 917, 26 U.S.C. 7805 )