Certificate of Purchaser of Chemicals That Will Be Resold for Use by the Second Purchaser as a Feedstock
(To support tax-free sales under section 4682(d)(2) of the Internal Revenue Code.)
Date _______________________________
The undersigned purchaser ("Purchaser") hereby certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from
_______________________________
(name and address of seller)
will be resold by Purchaser to persons (Second Purchasers) that certify to Purchaser that they are purchasing the ozone-depleting chemicals for use as a feedstock (as defined in § 52.4682-1(c)(3) of the Environmental Tax Regulations).
Product | Percentage |
CFC-11 | |
CFC-12 | |
CFC-113 | |
CFC-114 | |
CFC-115 | |
Carbon tetrachloride | |
Methyl chloroform | |
Other (specify) |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(d)(2)(B) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than for the purpose set forth in this certificate may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the sales covered by this certificate and will make such records available for inspection by Government officers. Purchaser also will retain and make available for inspection by Government officers the certificates of its Second Purchasers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified Purchaser that the right to provide a certificate has been withdrawn from any Second Purchaser who will purchase ozone-depleting chemicals to which this certificate applies.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Signature
_______________________________
Printed or typed name of person signing
_______________________________
Title of person signing
_______________________________
Name of Purchaser
_______________________________
Address
_______________________________
_______________________________
Taxpayer Identifying Number
Certificate of Purchaser of Chemicals That Will Be Used by the Purchaser as a Feedstock
(To support tax-free sales under section 4682(d)(2) of the Internal Revenue Code.)
Date _______________________________
The undersigned purchaser ("Purchaser") hereby certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from
_______________________________
(name and address of seller)
will be used by Purchaser as a feedstock (as defined in § 52.4682-1(c)(3) of the Environmental Tax Regulations).
Product | Percentage | Kilograms to be transformed |
CFC-11 | ||
CFC-12 | ||
CFC-113 | ||
CFC-114 | ||
CFC-115 | ||
Carbon tetrachloride | ||
Methyl chloroform | ||
Other (specify) |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(d)(2)(B) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use of the ozone-depleting chemicals to which this certificate applies other than as a feedstock may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the use as a feedstock of the ozone-depleting chemicals to which this certificate applies and will make such records available for inspection by Government officers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Signature
_______________________________
Printed or typed name of person signing
_______________________________
Title of person signing
_______________________________
Name of Purchaser
_______________________________
Address
_______________________________
_______________________________
Taxpayer Identifying Number
Certificate of Purchaser of Chemicals That Will Be Resold for Use by the Second Purchaser in the Manufacture of Rigid Foam Insulation
(To support tax-free or tax-reduced sales under section 4682(g) of the Internal Revenue Code.)
Effective Date _______________________________
Expiration Date _______________________________
(not after 12/31/93)
The undersigned purchaser ("Purchaser") hereby certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from
_______________________________
(name and address of seller)
will be resold by Purchaser to persons (Second Purchasers) that certify to Purchaser that they are purchasing the ozone-depleting chemicals for use in the manufacture of rigid foam insulation (as defined in § 52.4682-1(d)(3) and (4) of the Environmental Tax Regulations).
Product | Percentage |
CFC-11 | |
CFC-12 | |
CFC-113 | |
CFC-114 | |
CFC-115 | |
Carbon tetrachloride | |
Methyl chloroform | |
Other (specify) |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(3) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than for the purpose set forth in this certificate may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the sales covered by this certificate and will make such records available for inspection by Government officers. Purchaser also will retain and make available for inspection by Government officers the certificates of its Second Purchasers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified Purchaser that the right to provide a certificate has been withdrawn from any Second Purchaser who will purchase ozone-depleting chemicals to which this certificate applies.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Signature
_______________________________
Printed or typed name of person signing
_______________________________
Title of person signing
_______________________________
Name of Purchaser
_______________________________
Address
_______________________________
_______________________________
Taxpayer Identifying Number
Certificate of Purchaser of Chemicals That Will Be Used by the Purchaser in the Manufacture of Rigid Foam Insulation
(To support tax-free or tax-reduced sales under section 4682(g) of the Internal Revenue Code.)
Effective Date _______________________________
Expiration Date _______________________________
(not after 12/31/93)
The undersigned purchaser ("Purchaser") hereby certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from
_______________________________
(name and address of seller)
will be used by Purchaser in the manufacture of rigid foam insulation (as defined in § 52.4682-1(d) (3) and (4) of the Environmental Tax Regulations).
Product | Percentage |
CFC-11 | |
CFC-12 | |
CFC-113 | |
CFC-114 | |
CFC-115 | |
Carbon tetrachloride | |
Methyl chloroform | |
Other (specify) |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(3) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than in the manufacture of rigid foam insulation may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the use in the manufacture of rigid foam insulation of the ozone-depleting chemicals to which this certificate applies and will make such records available for inspection by Government officers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Signature
_______________________________
Printed or typed name of person signing
_______________________________
Title of person signing
_______________________________
Name of Purchaser
_______________________________
Address
_______________________________
_______________________________
Taxpayer Identifying Number
CERTIFICATE OF PURCHASER OF CHEMICALS THAT WILL BE RESOLD FOR USE BY THE SECOND PURCHASER AS MEDICAL STERILANTS
(TO SUPPORT TAX-REDUCED SALES UNDER SECTION 4682(G)(4) OF THE INTERNAL REVENUE CODE.)
Effective Date _______________________________
Expiration Date _______________________________
(not after 12/31/93)
The undersigned purchaser (Purchaser) certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from:
_______________________________
(Name of seller)
_______________________________
(Address of seller)
will be resold by Purchaser to persons (Second Purchasers) that certify to Purchaser that they are purchasing the ozone-depleting chemicals for use as medical sterilants (as defined in § 52.4682-1(g)(3) of the Environmental Tax Regulations).
Product | Percentage |
CFC-12 | __________ |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(4) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than for the purpose set forth in this certificate may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the sales covered by this certificate and will make such records available for inspection by Government officers. Purchaser also will retain and make available for inspection by Government officers the certificates of its Second Purchasers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified Purchaser that the right to provide a certificate has been withdrawn from any Second Purchaser who will purchase ozone-depleting chemicals to which this certificate applies.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Name of Purchaser
_______________________________
Address of Purchaser
_______________________________
_______________________________
Taxpayer Identifying Number of Purchaser
_______________________________
Title of person signing
_______________________________
Printed or typed name of person signing
_______________________________
Signature
CERTIFICATE OF PURCHASER OF CHEMICALS THAT WILL BE USED BY THE PURCHASER AS MEDICAL STERILANTS
(TO SUPPORT TAX-REDUCED SALES UNDER SECTION 4682(G)(4) OF THE INTERNAL REVENUE CODE.)
Effective Date _______________________________
Expiration Date _______________________________
(not after 12/31/93)
The undersigned purchaser (Purchaser) certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from:
_______________________________
(Name of seller)
_______________________________
(Address of seller)
will be used by Purchaser as medical sterilants (as defined in § 52.4682-1(g)(3) of the Environmental Tax Regulations).
Product | Percentage |
CFC-12 | __________ |
This certificate applies to (check and complete as applicable):
______ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
______ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
______ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(4) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than as medical sterilants may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the use as medical sterilants of the ozone-depleting chemicals to which this certificate applies and will make such records available for inspection by Government officers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Name of Purchaser
_______________________________
Address of Purchaser
_______________________________
_______________________________
Taxpayer Identifying Number of Purchaser
_______________________________
Title of person signing
_______________________________
Printed or typed name of person signing
_______________________________
Signature
CERTIFICATE OF PURCHASER OF CHEMICALS THAT WILL BE RESOLD FOR USE BY THE SECOND PURCHASER AS PROPELLANTS IN METERED-DOSE INHALERS
(TO SUPPORT TAX-REDUCED SALES UNDER SECTION 4682(G)(4) OF THE INTERNAL REVENUE CODE.)
Date _______________________________
The undersigned purchaser (Purchaser) certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from:
_______________________________
(Name of seller)
_______________________________
(Address of seller)
will be resold by Purchaser to persons (Second Purchasers) that certify to Purchaser that they are purchasing the ozone-depleting chemicals for use as propellants in metered-dose inhalers (as defined in § 52.4682-1(h)(3) of the Environmental Tax Regulations).
Product | Percentage |
CFC-11 | ________ |
CFC-12 | ________ |
CFC-114 | ________ |
This certificate applies to (check and complete as applicable):
________ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
________ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
________ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
________ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(4) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than for the purpose set forth in this certificate may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the sales covered by this certificate and will make such records available for inspection by Government officers. Purchaser also will retain and make available for inspection by Government officers the certificates of its Second Purchasers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. In addition, the Internal Revenue Service has not notified Purchaser that the right to provide a certificate has been withdrawn from any Second Purchaser who will purchase ozone-depleting chemicals to which this certificate applies.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Name of Purchaser
_______________________________
Address of Purchaser
_______________________________
_______________________________
Taxpayer Identifying Number of Purchaser
_______________________________
Title of person signing
_______________________________
Printed or typed name of person signing
_______________________________
Signature
CERTIFICATE OF PURCHASER OF CHEMICALS THAT WILL BE USED BY THE PURCHASER AS PROPELLANTS IN METERED-DOSE INHALERS
(TO SUPPORT TAX-REDUCED SALES UNDER SECTION 4682(G)(4) OF THE INTERNAL REVENUE CODE.)
Date _______________________________
The undersigned purchaser (Purchaser) certifies the following under penalties of perjury:
The following percentage of ozone-depleting chemicals purchased from:
_______________________________
(Name of seller)
_______________________________
(Address of seller)
will be used by Purchaser as propellants in metered-dose inhalers (as defined in § 52.4682-1(h)(3) of the Environmental Tax Regulations).
Product | Percentage |
CFC-11 | ________ |
CFC-12 | ________ |
CFC-114 | ________ |
This certificate applies to (check and complete as applicable):
________ All shipments to Purchaser at the following location(s):
_______________________________
_______________________________
_______________________________
________ All shipments to Purchaser under the following Purchaser account number(s):
_______________________________
_______________________________
_______________________________
________ All shipments to Purchaser under the following purchase order(s):
_______________________________
_______________________________
_______________________________
________ One or more shipments to Purchaser identified as follows:
_______________________________
_______________________________
_______________________________
Purchaser will not claim a credit or refund under section 4682(g)(4) of the Internal Revenue Code for any ozone-depleting chemicals covered by this certificate.
Purchaser understands that any use by Purchaser of the ozone-depleting chemicals to which this certificate applies other than as propellants in metered-dose inhalers may result in the withdrawal by the Internal Revenue Service of Purchaser's right to provide a certificate.
Purchaser will retain the business records needed to document the use as propellants in metered-dose inhalers of the ozone-depleting chemicals to which this certificate applies and will make such records available for inspection by Government officers.
Purchaser has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.
Purchaser understands that the fraudulent use of this certificate may subject Purchaser and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
_______________________________
Name of Purchaser
_______________________________
Address of Purchaser
_______________________________
_______________________________
Taxpayer Identifying Number of Purchaser
_______________________________
Title of person signing
_______________________________
Printed or typed name of person signing
_______________________________
Signature
26 C.F.R. §52.4682-2