Appendix B--Model Certificate A. Summary: This is an example of a First Taxpayer's Report, which reports the first person to pay tax on a taxable fuel (gasoline,
diesel fuel,
or kerosene) that may go through multiple taxable events. It contains the following text:FIRST TAXPAYER'S REPORT.
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“1. First Taxpayer's name, address, and employer identification number” field
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“2. Name, address, and employer identification number of the buyer of the taxable fuel subject to tax” field
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“3. Date and location of removal, entry, or sale” field
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“4. Volume and type of taxable fuel removed, entered, or sold” field
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“5. Check type of taxable event:”
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“Removal from refinery”
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“Entry into United States”
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“Bulk transfer from terminal by unregistered position holder”
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“Bulk transfer not received at an approved terminal”
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“Sale within the bulk transfer/terminal system”
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“Removal at the terminal rack”
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“Removal or sale by the blender”
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“6. Amount of federal excise tax paid on account of the removal, entry, or sale” field
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The undersigned taxpayer (
“Taxpayer”) has not received, and will not claim, a credit with respect to, or a refund of, the tax on the taxable fuel to which this
form relates.Under penalties of perjury, Taxpayer declares that Taxpayer has examined this statement, including any accompanying
schedules and statements,
and to the best of Taxpayer's knowledge and belief, they are true, correct and complete.
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“Signature and date signed” field
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“Printed or typed name of person signing this report” field
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“Title” field
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