Exemption Certificate
(For use by purchasers of articles for use as fuel supplies, ships stores, sea stores, of legitimate equipment on certain vessels or aircraft (sections 4221 and 4222 of the Internal Revenue Code of 1954).)
(Date) __________________________, 19____.
I, the undersigned purchaser, hereby certify that I am the ________________ (Owner, charterer, or authorized agent) of __________ (Name of company and vessel) and that: (Check applicable type of certificate)
____ the article or articles specified in the accompanying order, or on the reverse side hereof, (or)
____ all orders placed by the purchaser for the period commencing (Date) ______ and ending (Date) ______ (period not to exceed 12 calendar quarters), will be used only for fuel supplies, ships' stores, sea stores, or legitimate equipment on a vessel belonging to one of the following classes of vessels to which section 4221 of the Internal Revenue Code applies: (Check class to which vessel belongs.)
(1) Vessels engaged in foreign trade. | |
(2) Vessels engaged in trade between the Atlantic and Pacific ports of the United States. | |
(3) Vessels engaged in trade between the United States and any of its possessions. | |
(4) Vessels employed in the fisheries or whaling business. | |
(5) Vessels of war of the United States or a foreign nation. |
If the articles are purchased for use on civil aircraft engaged in trade as specified in (1) or (3) above, state the name of the country in which the aircraft is registered:
_______________________________
I understand that if the articles are used for any purpose other than as stated in this certificate, or are resold or otherwise disposed of, I must report such fact to the manufacturer. I understand that this certificate may not be used in purchasing articles tax free for use as fuel supplies, etc., on pleasure vessels, or on any type of aircraft except that (i) civil aircraft employed in foreign trade or trade between the United States and any of its possessions, and (ii) aircraft owned by the United States or any foreign country and constituting a part of the armed forces thereof.
I understand that the fraudulent use of this certificate to secure exemption will subject me and all parties making such fraudulent use of this certificate 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. I also understand that I must be prepared to establish by satisfactory evidence the purpose for which the article was used.
_______________________________
(Signature)
_______________________________
(Address)
26 C.F.R. §48.4221-4