The certificate must be in substantially the following form:
STATEMENT OF ULTIMATE VENDOR
(For use in claiming credit or refund of overpayment determined under section 6416(b)(2) (other than section 6416(b)(2)(E)) of the Internal Revenue Code.)
The undersigned or the
_______________________________
(Name of ultimate vendor if other than undersigned) of which the undersigned is (Title), is the ultimate vendor of the article specified below or on the reverse side hereof.
The article was purchased by the ultimate vendor tax-paid and was thereafter exported, used, sold, or resold (as indicated below or on the reverse side hereof).
The ultimate vendor possesses
_______________________________
(Proof of exportation in respect of the article, or a certificate as to use executed by the ultimate purchaser of the article)
The _______________________________
(Proof of exportation or certificate)
(1) is retained by the ultimate vendor, (2) will, upon request, be forwarded to
_______________________________
(Name or person who paid the tax)
at any time within 3 years from the date of this statement for use by that person to establish that credit or refund is due in respect of the article, and (3) will otherwise be held by the ultimate vendor for the required 3-year period.
According to the best knowledge and belief of the undersigned, no statement in respect of the
_______________________________
(Proof of exportation or certificate)
has previously been executed, and the undersigned understands that the fraudulent use of this statement may, under section 7201, subject the undersigned or any other party making such fraudulent use to a fine of not more than $10,000, or imprisonment for not more than 5 years, or both, together with the costs of prosecution.
_______________________________
(Signature)
_______________________________
(Address)
_______________________________
(Date)
Vendor's invoice | Articles | Date of resale | Quantity | Exported or use made or to be made (specify) |
STATEMENT OF ULTIMATE VENDOR
(For use in claiming credit or refund of overpayment determined under section 6416 (b)(2)(E), Internal Revenue Code, involving tires or inner tubes sold on or with another article.)
The undersigned or the
_______________________________
(Name of ultimate vendor of second article if other than undersigned)
of which the undersigned is (Title), is the
ultimate vendor of an article, specified below or on the reverse side hereof, on which or with which a tax-paid tire or inner tube was sold.
The ultimate vendor possesses
_______________________________
(Proof of exportation in respect of the article on which or with which the tire or inner tube was sold, or a certificate as to use of the article executed by the ultimate purchaser of the article)
The
_______________________________
(Proof of exportation or certificate) (1) is retained by the ultimate vendor, (2) will, upon request, be forwarded to
_______________________________
(Name of person who paid the tax on the tire or inner tube)
at any time within 3 years from the date of this statement for use in establishing that credit or refund is due in respect of the tire or inner tube, and (3) will otherwise be held by the ultimate vendor for the required 3-year period.
According to the best knowledge and belief of the undersigned, no statement in respect of the
_______________________________
(Proof of exportation or certificate)
has previously been executed, and the undersigned understands that the fraudulent use of this statement may, under section 7201, subject the undersigned or any other party making such fraudulent use to a fine of not more than $10,000, or imprisonment for not more than 5 years, or both, together with the costs of prosecution.
_______________________________
(Signature)
_______________________________
(Address)
_______________________________
(Date)
Tires or inner tubes (specify and state quantity) | Vendor's invoice on second article | Second article (specify and state quantity) | Date of sale of second article | Exported or use made of or to be made (specify in respect of second article) |
26 C.F.R. §48.6416(b)(2)-3