See section 6416(b)(2)(F) and paragraph (b)(6) of § 48.6416(b)-2 for the circumstances under which credit or refund of tax is available for tax-paid tires or tubes that are resold for the purposes described in this paragraph (a).
Statement of Manufacturer's Vendee
(To support tax-free sales of tires or inner tubes by the manufacturer thereof for use on or in connection with the sale of another article (section 4221(e)(2) of the Internal Revenue Code))
(Date) ____________________________, 19____.
I certify that I, or the __________________, (Name of purchaser if other than undersigned) of which I am __________________ (Title) am/is in the business of selling __________________ (Products handled) and hold(s) certificate of registry No. ____ issued by the District Director of Internal Revenue at __________________; and that the tires or inner tubes which were purchased or shipped on ____________________, 19____, as specified on the back hereof, have been used on or in connection with the sale of __________________ (Products sold) by such undersigned.
Check one
____ for export by __________________ (Name of carrier) to __________________ (Name of foreign country or U.S. possession) and was so exported on ____________________, 19____ (Date). (A copy of the bill of lading or other proof of exportation is attached.)
____ for use as supplies on __________________ (Name of vessel or aircraft) which is registered in __________________ (Name of country in which vessel or aircraft is registered).
____ to __________________ (Name of State or local government).
____ to __________________ (Name and address of the nonprofit educational organization).
I understand that the fraudulent use of this certificate for the purpose of substantiating the tax-free sale will subject me and all parties making such fraudulent use of this certificate to revocation of the privilege of purchasing articles tax free and 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.
_______________________________
(Signature)
_______________________________
(Address)
26 C.F.R. §48.4221-7