Table 3-1. Model Certificate A. Summary: This is an example of a Certificate of Farming Use Or State Use that must be maintained by the vendor to claim credit
of excise tax
on the sale of undyed diesel fuel or undyed kerosene.CERTIFICATE OF FARMING USE OR STATE USE. (To support vendor's claim for credit or payment under section 6427 of the Internal Revenue Code)
“Name, Address, and Employer Identification Number of Vendor” fieldThe undersigned buyer (Buyer) hereby certifies the following under penalties of perjury:
| A. Buyer will use the diesel fuel or kerosene to which this certificate relates--(check one):
|
| (checkbox)
“1. On a farm for farming purposes (as defined in section 48.6420-4 of the Manufacturers and Retailers Excise Tax Regulations)
and Buyer is the
owner, tenant, or operator of the farm on which the fuel will be used;”
|
| (checkbox)
“2. On a farm (as defined in section 48.6420-4(c)) for any of the purposes described in paragraph (d) of that section (relating
to cultivating,
raising, or harvesting) and Buyer is not the owner, tenant, or operator of the farm on which the fuel will be used; or”
|
| (checkbox)
“3. For the exclusive use of a State or local government, or the District of Columbia.”
|
|
| B. This certificate applies to the following (complete as applicable):
|
| 1. If this is a single purchase certificate, check here (checkbox) and enter:
|
|
“a. Invoice or delivery ticket number” field
|
|
“b. Number of gallons” field
|
|
| 2. If this is a certificate covering all purchases under a specified account or order number, check here (checkbox) and enter:
|
|
“a. Effective date” field
|
|
“b. Expiration date” field (period not to exceed 1 year after effective date)
|
|
“c. Buyer account or order number” field
|
|
|
| Buyer will provide a new certificate to the vendor if any information in this certificate changes.
|
| If Buyer uses the diesel fuel or kerosene to which this certificate relates for a purpose other than stated in the certificate,
Buyer will be
liable for any tax.
|
| Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making such fraudulent use
of this
certificate to a fine or imprisonment, or both, together with the costs of prosecution.
|
|
“Printed or typed name of person signing” field
|
|
“Title of person signing” field
|
|
“Name of Buyer” field
|
|
“Employer identification number” field
|
|
“Address of Buyer” field
|
|
“Signature and date signed” field
|
