Appendix B--Model Certificates H and I. Summary: These are examples of certificates provided to claim credit or refund of excise tax on aviation fuel. The first certificate
reports
the information about the first producer of aviation fuel and the second reports the information about a subsequent seller
of aviation fuel. They
contain the following text:Model Certificate H. FIRST PRODUCER'S REPORT.
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“First Producer's name, address, and employer identification number” field
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“Buyer's name, address, and employer identification number” field
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“Date and location of taxable sale” field
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“Volume and type of aviation fuel sold” field
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“Amount of federal excise tax paid on account of the sale” field
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Under penalties of perjury. First Producer declares that First Producer has examined this statement, including any accompanying
schedules and
statements, and, to the best of First Producer's knowledge and belief, it is true, correct and complete.
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“Printed or typed name of person signing” field
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“Title of person signing” field
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“Signature and date signed” field
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Model Certificate I. STATEMENT OF SUBSEQUENT SELLER (AVIATION FUEL).
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“Name, address, and employer identification number of seller in subsequent sale” field
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“Name, address, and employer identification number of buyer in subsequent sale” field
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“Date and location of subsequent sale” field
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“Volume and type of aviation fuel sold” field
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The undersigned seller (Seller) has received the copy of the first producer's report provided with this statement in connection
with Seller's
purchase of the aviation fuel described in this statement.Under penalties of perjury, Seller declares that Seller has examined
this statement, including any accompanying schedules and statements, and,
to the best of Seller's knowledge and belief, it is true, correct and complete.
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“Printed or typed name of person signing” field
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“Title of person signing” field
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“Signature and date signed” field
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