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Page Last Reviewed or Updated: 13-Mar-2014

The File 2011 State Taxes

File 2011 state taxes 18. File 2011 state taxes   Appendix This appendix contains models of the certificates, waivers, reports, and statements discussed in Part One. File 2011 state taxes Model Certificate A   STATEMENT OF SUBSEQUENT SELLER     1. File 2011 state taxes                 Name, address, and employer identification number of seller in subsequent sale             2. File 2011 state taxes                 Name, address, and employer identification number of the buyer in subsequent sale             3. File 2011 state taxes         Date and location of subsequent sale             4. File 2011 state taxes         Volume and type of taxable fuel sold               The undersigned seller (“Seller”) has received the copy of the first taxpayer's report provided with this statement in     connection with Seller's purchase of the taxable fuel described in this statement. File 2011 state taxes       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, they are true, correct and complete. File 2011 state taxes                   Signature and date signed                   Printed or typed name of person signing this report                   Title—   Model Certificate B   FIRST TAXPAYER'S REPORT   1. File 2011 state taxes                     First Taxpayer's name, address and employer identification number     2. File 2011 state taxes                     Name, address, and employer identification number of the buyer of the taxable fuel subject to tax     3. File 2011 state taxes           Date and location of removal, entry, or sale       4. File 2011 state taxes           Volume and type of taxable fuel removed, entered or sold     5. File 2011 state taxes Check type of taxable event:         Removal from refinery         Entry into United States         Bulk transfer from terminal by unregistered position holder       Bulk transfer not received at an approved terminal       Sale within the bulk transfer/terminal system       Removal at the terminal rack         Removal or sale by the blender                   6. File 2011 state taxes           Amount of federal excise tax paid on account of the removal, entry, or sale                   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. File 2011 state taxes       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. File 2011 state taxes             Signature and date signed               Printed or typed name of person signing this report               Title     Model Certificate C   NOTIFICATION CERTIFICATE OF TAXABLE FUEL REGISTRANT                           Name, address, and employer identification number of person receiving certificate       The undersigned taxable registrant (“Registrant”) hereby certifies under penalties of perjury that Registrant is registered     by the Internal Revenue Service with registration number and that Registrant's registration has not     been revoked or suspended by the Internal Revenue Service. File 2011 state taxes                 Registrant understands that the fraudulent use of this certificate may subject Registrant and all parties making such     fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes                       Signature and date signed                         Printed or typed name of person signing                         Title of person signing                         Name of Registrant                         Employer identification number                         Address of Registrant     Model Certificate D   CERTIFICATE OF PERSON BUYING GASOLINE BLENDSTOCKS FOR USE OTHER THAN IN THE PRODUCTION OF FINISHED GASOLINE     (To support tax-free sales (other than LUST) under section 4081 of the Internal Revenue Code. File 2011 state taxes )                 Name, address, and employer identification number of seller       The undersigned buyer (“Buyer”) hereby certifies the following under penalties of perjury:       The gasoline blendstocks to which this certificate relates will not be used to produce finished gasoline. File 2011 state taxes       This certificate applies to the following (complete as applicable):       If this is a single purchase certificate, check here and enter:     1. File 2011 state taxes Invoice or delivery ticket number       2. File 2011 state taxes (number of gallons) of(type of gasoline blendstocks)       If this is a certificate covering all purchases under a specified account or order number, check here and enter:     1. File 2011 state taxes Effective date       2. File 2011 state taxes Expiration date       (period not to exceed 1 year after the effective date)       3. File 2011 state taxes Type (or types) of gasoline blendstocks     4. File 2011 state taxes Buyer's account or order number         Buyer will not claim a credit or refund under section 6427(h) of the Internal Revenue Code for any gasoline blendstocks     covered by this certificate. File 2011 state taxes         Buyer will provide a new certificate to the seller if any information in this certificate changes. File 2011 state taxes       If Buyer resells the gasoline blendstocks to which this certificate relates, Buyer will be liable for tax unless Buyer obtains a     certificate from the purchaser stating that the gasoline blendstocks will not be used to produce finished gasoline and otherwise complies with the conditions of §48. File 2011 state taxes 4081-4(b)(3) of the Manufacturers and Retailers Excise Tax Regulations. File 2011 state taxes       Buyer understands that if Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's     right to provide a certificate. File 2011 state taxes       Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. File 2011 state taxes     In addition, the Internal Revenue Service has not notified Buyer that the right to provide a certificate has been withdrawn from a purchaser to which Buyer sells gasoline blendstocks tax free. File 2011 state taxes       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. File 2011 state taxes             Signature and date signed               Printed or typed name of person signing               Title of person signing               Name of Buyer               Employer identification number               Address of Buyer     Model Certificate G   CERTIFICATE OF REGISTERED FEEDSTOCK USER     (To support tax-free removals and entries (other than LUST) of kerosene under section 4082 of the Internal Revenue Code. File 2011 state taxes )         (Buyer) certifies the following under penalties of perjury:       Name of buyer         Buyer is a registered feedstock user with registration number . File 2011 state taxes Buyer's registration has not been revoked     or suspended. File 2011 state taxes         The kerosene to which this certificate applies will be used by Buyer for a feedstock purpose. File 2011 state taxes                 This certificate applies to percent of Buyer's purchases from (name, address, and employer     identification number of seller) as follows (complete as applicable):       1. File 2011 state taxes A single purchase on invoice or delivery ticket number . File 2011 state taxes                 2. File 2011 state taxes All purchases between (effective date) and (expiration date) (period not to exceed     one year after the effective date) under account or order number(s) . File 2011 state taxes If this certificate applies only to Buyer's     purchases for certain locations, check here and list the locations. File 2011 state taxes                                   If Buyer sells the kerosene to which this certificate relates, Buyer will be liable for tax on that sale. File 2011 state taxes                 Buyer will provide a new certificate to the seller if any information in this certificate changes. File 2011 state taxes                 If Buyer violates the terms of this certificate, the Internal Revenue Service may revoke the Buyer's registration. File 2011 state taxes                 Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making any fraudulent use of     this certificate to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes             Printed or typed name of person signing               Title of person signing               Employer identification number               Address of Buyer               Signature and date signed     Model Certificate J   CERTIFICATE OF PERSON BUYING COMPRESSED NATURAL GAS (CNG) FOR A NONTAXABLE USE     (To support tax-free sales of CNG under section 4041 of the Internal Revenue Code. File 2011 state taxes )                                         Name, address, and employer identification number of seller                   (“Buyer”) certifies the following under penalties of perjury:     Name of buyer                     The CNG to which this certificate relates will be used in a nontaxable use. File 2011 state taxes       This certificate applies to the following (complete as applicable):               If this is a single purchase certificate, check here and enter:       1. File 2011 state taxes Invoice or delivery ticket number       2. File 2011 state taxes (Gasoline gallon equivalents)       If this is a certificate covering all purchases under a specified account or order number, check here and enter:         1. File 2011 state taxes Effective date         2. File 2011 state taxes Expiration date         (period not to exceed 1 year after the effective date)         3. File 2011 state taxes Buyer's account or order number       Buyer will not claim a credit or refund under section 6427 of the Internal Revenue Code for any CNG to which this certificate relates. File 2011 state taxes       Buyer will provide a new certificate to the seller if any information in this certificate changes. File 2011 state taxes       Buyer understands that if Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's     right to provide a certificate. File 2011 state taxes       Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. File 2011 state taxes     In addition, the Internal Revenue Service has not notified Buyer that the right to provide a certificate has been withdrawn     from a purchaser to which Buyer sells CNG tax free. File 2011 state taxes       Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making any fraudulent use     of this certificate to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes             Printed or typed name of person signing               Title of person signing             Employer identification number               Address of Buyer               Signature and date signed     Model Certificate K   CERTIFICATE OF PERSON BUYING KEROSENE FOR USE IN AVIATION FOR     COMMERCIAL AVIATION OR NONTAXABLE USE     (To support operator liability for tax on removals of kerosene for use in aviation directly into the fuel tank of an aircraft in commercial aviation pursuant to § 4081 of the Internal Revenue Code or to support a tax rate of zero under § 4041(c) pursuant to §§4041(c) and 4082. File 2011 state taxes )           Name, address, and employer identification number of position holder       The undersigned aircraft operator (“Buyer”) hereby certifies the following under the penalties of perjury:       The kerosene for use in aviation to which this certificate relates is purchased (check one): for     use on a farm for farming purposes; for use in foreign trade (reciprocal benefits required for foreign registered airlines); for use in certain helicopter and fixed-wing air ambulance uses; for use other than as a fuel in the propulsion engine of an aircraft; for the exclusive use of a qualified blood collector organization; for the exclusive use of a nonprofit educational organization; for the exclusive use of a state; for use in an aircraft owned by an aircraft museum; for use in military aircraft; or for use in commercial aviation (other than foreign trade). File 2011 state taxes       With respect to kerosene for use in aviation purchased after June 30, 2005, for use in commercial aviation     (other than foreign trade), Buyer's registration number is. File 2011 state taxes Buyer's registration has not been suspended or revoked by the Internal Revenue Service. File 2011 state taxes       This certificate applies to the following (complete as applicable):     This is a single purchase certificate:       1. File 2011 state taxes Invoice or delivery ticket number       2. File 2011 state taxes Number of gallons     This is a certificate covering all purchases under a specified account or order number:       1. File 2011 state taxes Effective date       2. File 2011 state taxes Expiration date (period not to exceed 1 year after the effective date)       3. File 2011 state taxes Buyer's account number       Buyer agrees to provide the person liable for tax with a new certificate if any information in this certificate changes. File 2011 state taxes       If the kerosene for use in aviation to which this certificate relates is being bought for use in commercial aviation     (other than foreign trade), Buyer is liable for tax on its use of the fuel and will pay that tax to the government. File 2011 state taxes       If Buyer sells or uses the kerosene for use in aviation to which this certificate relates for a use other than the use     stated above, Buyer will be liable for tax. File 2011 state taxes       Buyer understands that it must be prepared to establish by satisfactory evidence the purpose for which the     fuel purchased under this certificate was used. File 2011 state taxes     Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. File 2011 state taxes     If Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's right to provide a certificate. File 2011 state taxes       The fraudulent use of this certificate may subject Buyer and all parties making any fraudulent use of this certificate     to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Waiver L WAIVER FOR USE BY ULTIMATE PURCHASERS OF KEROSENE FOR CERTAIN USES IN AVIATION (To support vendor's claim for a credit or payment under § 6427(l)(4)(C)(i) of the Internal Revenue Code. File 2011 state taxes )               Name, Address, and Employer Identification Number of Ultimate Vendor     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. File 2011 state taxes The kerosene to which this waiver relates is purchased for — (check one):       1. File 2011 state taxes □ Use on a farm for farming purposes,       2. File 2011 state taxes □ Use in foreign trade (reciprocal benefits required for foreign registered airlines),       3. File 2011 state taxes □ Use in certain helicopter and fixed-wing air ambulance uses,       4. File 2011 state taxes □ The exclusive use of a qualified blood collector organization,       5. File 2011 state taxes □ The exclusive use of a nonprofit educational organization,       6. File 2011 state taxes □ Use in an aircraft owned by an aircraft museum,       7. File 2011 state taxes □ Use in military aircraft, or       8. File 2011 state taxes □ Use in commercial aviation (other than foreign trade). File 2011 state taxes     B. File 2011 state taxes This waiver applies to the following (complete as applicable):       This is a single purchase waiver:           1. File 2011 state taxes Invoice or delivery ticket number           2. File 2011 state taxes Number of gallons       This is a waiver covering all purchases under a specified account or order number:           1. File 2011 state taxes Effective date           2. File 2011 state taxes Expiration date (period not to exceed 1 year after the effective date)           3. File 2011 state taxes Buyer's account number       Buyer will provide a new waiver to the vendor if any information in this waiver changes. File 2011 state taxes       If Buyer uses the kerosene for use in aviation to which this waiver relates for a use other than the use stated above, Buyer will be liable for tax. File 2011 state taxes       Buyer understands that by signing this waiver, Buyer gives up its right to claim any credit or payment for the kerosene for use in aviation used in a nontaxable use. File 2011 state taxes       Buyer acknowledges that it has not and will not claim any credit or payment for the kerosene for use in aviation to which this waiver relates. File 2011 state taxes       Buyer understands that the fraudulent use of this waiver may subject Buyer and all parties making such fraudulent use of this waiver to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Certificate M   CERTIFICATE FOR STATE USE OR NONPROFIT EDUCATIONAL     ORGANIZATION USE     (To support vendor's claim for a credit or payment under § 6416(a)(4) of the Internal Revenue Code. File 2011 state taxes )                       Name, address, and employer identification number of ultimate vendor       The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under the penalties of perjury:       Buyer will use the gasoline or aviation gasoline to which this certificate relates (check one):     For the exclusive use of a state or local government; or     For the exclusive use of a nonprofit educational organization. File 2011 state taxes       This certificate applies to the following (complete as applicable):     This is a single purchase certificate:       1. File 2011 state taxes Invoice or delivery ticket number       2. File 2011 state taxes Number of gallons     This is a certificate covering all purchases under a specified account or order number:       1. File 2011 state taxes Effective date       2. File 2011 state taxes Expiration date (period not to exceed 1 year after the effective date)       3. File 2011 state taxes Buyer's account number       Buyer will provide a new certificate to the vendor if any information in this certificate changes. File 2011 state taxes       Buyer understands that by signing this certificate, Buyer gives up its right to claim any credit or payment for the gasoline or aviation gasoline to which this certificate relates. File 2011 state taxes       Buyer acknowledges that it has not and will not claim any credit or payment for the gasoline or aviation gasoline to which this certificate relates. File 2011 state taxes       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. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Waiver N   WAIVER FOR USE BY ULTIMATE PURCHASERS OF DIESEL FUEL OR     KEROSENE USED IN INTERCITY BUS TRANSPORTATION     (To support vendor's claim for a credit or payment under § 6427 of the Internal Revenue Code. File 2011 state taxes )                       Name, address, and employer identification number of ultimate vendor       The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under the penalties of perjury:       The diesel fuel or kerosene to which this waiver relates is purchased for use in intercity bus transportation. File 2011 state taxes       This waiver applies to the following (complete as applicable):     This is a single purchase waiver:       1. File 2011 state taxes Invoice or delivery ticket number       2. File 2011 state taxes Number of gallons     This is a waiver covering all purchases under a specified account or order number:       1. File 2011 state taxes Effective date       2. File 2011 state taxes Expiration date (period not to exceed 1 year after the effective date)       3. File 2011 state taxes Buyer's account number       Buyer will provide a new waiver to the vendor if any information in this waiver changes. File 2011 state taxes       If Buyer uses the diesel fuel or kerosene to which this waiver relates for a use other than in intercity bus transportation, Buyer will be liable for tax. File 2011 state taxes       Buyer understands that by signing this waiver, Buyer gives up its right to claim any credit or payment for the diesel fuel or kerosene used in intercity bus transportation. File 2011 state taxes       Buyer acknowledges that it has not and will not claim any credit or payment for the diesel fuel or kerosene to which this waiver relates. File 2011 state taxes       Buyer understands that the fraudulent use of this waiver may subject Buyer and all parties making such fraudulent use of this waiver to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Certificate O   CERTIFICATE FOR BIODIESEL     Certificate Identification Number:     (To support a claim related to biodiesel or a biodiesel mixture under section 6426 of the Internal Revenue Code. File 2011 state taxes )     The undersigned biodiesel producer (“Producer”) hereby certifies the following under penalties of perjury:   1. File 2011 state taxes             Producer's name, address, and employer identification number (EIN)   2. File 2011 state taxes             Name, address, and EIN of person buying the biodiesel from Producer   3. File 2011 state taxes       Date and location of sale to buyer   4. File 2011 state taxes This certificate applies to gallons of biodiesel. File 2011 state taxes   5. File 2011 state taxes Producer certifies that the biodiesel to which this certificate relates is:       % Agri-biodiesel (derived solely from virgin oils)       % Biodiesel other than agri-biodiesel       This certificate applies to the following sale:       Invoice or delivery ticket number       Total number of gallons of biodiesel sold under that invoice or delivery ticket number (including biodiesel not covered by this certificate)       Total number of certificates issued for that invoice or delivery ticket number   6. File 2011 state taxes             Name, address, and employer identification number of reseller to whom certificate is issued (only in the case of certificates reissued to a reseller after the return of the original certificate)   7. File 2011 state taxes Original Certificate Identification Number (only in the case of certificates reissued to a reseller after return of the original certificate). File 2011 state taxes       Producer is registered as a biodiesel producer with registration number . File 2011 state taxes  Producer's registration has not been suspended or revoked by the Internal Revenue Service. File 2011 state taxes       Producer certifies that the biodiesel to which this certificate relates in monoalkyl esters of long chain fatty acids derived from plant or animal matter that meets the requirements of the American Society of Testing and Materials D6751 and the registration requirements for fuels and fuel additives established by EPA under section 211 of the Clean Air Act (42 U. File 2011 state taxes S. File 2011 state taxes C. File 2011 state taxes 7545). File 2011 state taxes       Producer understands that the fraudulent use of this certificate may subject Producer and all parties making any fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes           Printed or typed name of person signing this certificate           Title of person signing           Signature and date signed   Model Certificate P CERTIFICATE OF STATE USE (To support vendor's claim for credit or payment under section 6427 of the Internal Revenue Code. File 2011 state taxes )               Name, Address, and Employer Identification Number of Vendor     The undersigned buyer (“Buyer”) hereby certifies the following under penalties of perjury:     A. File 2011 state taxes Buyer will use the diesel fuel or kerosene to which this certificate relates for the exclusive use of a state or local government, or the District of Columbia. File 2011 state taxes     B. File 2011 state taxes This certificate applies to the following (complete as applicable):       1. File 2011 state taxes   If this is a single purchase certificate, check here □ and enter:           a. File 2011 state taxes Invoice or delivery ticket number           b. File 2011 state taxes Number of gallons       2. File 2011 state taxes   If this is a certificate covering all purchases under a specified account or order number, check here □  and enter:           a. File 2011 state taxes Effective date           b. File 2011 state taxes Expiration date   (period not to exceed 1 year after effective date)           c. File 2011 state taxes Buyer's account or order number     ▪ Buyer will provide a new certificate to the vendor if any information in this certificate changes. File 2011 state taxes     ▪ 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. File 2011 state taxes     ▪ Buyer acknowledges that it has not and will not claim any credit or payment for the diesel fuel or kerosene to which this certificate relates. File 2011 state taxes     ▪ 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. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Certificate Q CERTIFICATE OF ULTIMATE PURCHASER OF KEROSENE FOR USE IN NONEXEMPT, NONCOMMERCIAL AVIATION (To support vendor's claim for credit or payment under section 6427(l)(4)(C)(ii) of the Internal Revenue Code. File 2011 state taxes )               Name, Address, and Employer Identification Number of Ultimate Vendor     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. File 2011 state taxes The kerosene to which this certificate relates is purchased for a nonexempt use in noncommercial aviation. File 2011 state taxes     B. File 2011 state taxes This certificate applies to the following (complete as applicable):       1. File 2011 state taxes   If this is a single purchase certificate, check here □ and enter:           a. File 2011 state taxes Invoice or delivery ticket number           b. File 2011 state taxes Number of gallons       2. File 2011 state taxes   This is a certificate covering all purchases under a specified account or order number:           a. File 2011 state taxes Effective date           b. File 2011 state taxes Expiration date   (period not to exceed 1 year after effective date)           c. File 2011 state taxes Buyer's account number     ▪ Buyer will provide a new certificate to the vendor if any information in this certificate changes. File 2011 state taxes     ▪ If Buyer uses the kerosene to which this certificate relates for a use other than the nontaxable use stated above, Buyer will be liable for tax. File 2011 state taxes     ▪ 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. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Certificate R CERTIFICATE OF BUYER OF TAXABLE FUEL FOR USE BY A STATE OR NONPROFIT EDUCATIONAL ORGANIZATION (To support credit card issuer's claim for credit, refund, or payment under section 6416(a)(4)(B) or section 6427(l)(5)(D) of the Internal Revenue Code. File 2011 state taxes )               Name, Address, and Employer Identification Number of Credit Card Issuer. File 2011 state taxes     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. File 2011 state taxes Buyer will use the taxable fuel to which this certificate relates for the exclusive use of a state; or     B. File 2011 state taxes Buyer will use the gasoline to which this certificate relates for the exclusive use of a nonprofit educational organization. File 2011 state taxes     C. File 2011 state taxes This certificate applies to all purchases made with the credit card identified below during the period specified:           a. File 2011 state taxes Effective date of certificate           b. File 2011 state taxes Expiration date of certificate   (period not to exceed 2 years after effective date)           c. File 2011 state taxes Buyer's account number     ▪ Buyer will provide a new certificate to the credit card issuer if any information in this certificate changes. File 2011 state taxes     ▪ Buyer understands that by signing this certificate, Buyer gives up its right to claim a credit or payment for the taxable fuel purchased with the credit card to which this certificate relates. File 2011 state taxes     ▪ Buyer acknowledges that it has not and will not claim any credit or payment for the taxable fuel purchased with the credit card to which this certificate relates. File 2011 state taxes     ▪ 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. File 2011 state taxes           Printed or typed name of person signing           Title of person signing           Name of Buyer           Employer identification number           Address of Buyer           Signature and date signed   Model Statement S   STATEMENT OF BIODIESEL RESELLER     (To support a claim related to biodiesel or a biodiesel mixture under section 6426 of the Internal Revenue Code. File 2011 state taxes )     The undersigned biodiesel producer (“Reseller”) hereby certifies the following under penalties of perjury:   1. File 2011 state taxes                   Reseller's name, address, and employer identification number (EIN)   2. File 2011 state taxes                   Name, address, and EIN of Reseller's buyer   3. File 2011 state taxes       Date and location of sale to buyer   4. File 2011 state taxes Volume of biodiesel sold   5. File 2011 state taxes Certificate Identification Number on the Certificate for Biodiesel       Reseller has bought the biodiesel described in the accompanying Certificate for Biodiesel and Reseller has no reason to believe that any information in the certificate is false. File 2011 state taxes       Reseller has not been notified by the Internal Revenue Service that its right to provide a certificate or statement has been withdrawn. File 2011 state taxes       Reseller understands that the fraudulent use of this statement may subject Reseller and all parties making any fraudulent use of this statement to a fine or imprisonment, or both, together with the costs of prosecution. File 2011 state taxes           Printed or typed name of person signing this certificate           Title of person signing           Signature and date signed   Prev  Up  Next   Home   More Online Publications