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Form 1040 For 2011 Tax Year

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Form 1040 For 2011 Tax Year

Form 1040 for 2011 tax year Index A Additional Medicare Tax, Reminder, Social Security and Medicare Taxes, Withholding the employee's share. Form 1040 for 2011 tax year Assistance (see Tax help) B Baby sitters (see Household employee) Baby-sitting costs (see Child and dependent care expenses) Business employers, employment tax payment option, Payment option for business employers. Form 1040 for 2011 tax year C Caretakers (see Household employee) Child and dependent care expenses, credit for, Can You Claim a Credit for Child and Dependent Care Expenses? Comments on publication, Comments and suggestions. Form 1040 for 2011 tax year Correcting Schedule H Schedule H attached to another form, How Can You Correct Schedule H? Schedule H filed by itself, How Can You Correct Schedule H? D Dependent care expenses, Can You Claim a Credit for Child and Dependent Care Expenses? Disability payments, state, State disability payments treated as wages. Form 1040 for 2011 tax year Domestic worker (see Household employee) Drivers (see Household employee) E Earned income credit (EIC), What Do You Need To Know About the Earned Income Credit? EIC notice, Notice about the EIC. Form 1040 for 2011 tax year Employer identification number (EIN), Employer identification number (EIN). Form 1040 for 2011 tax year Employing an alien legally (see Legal employee) Employment eligibility verification form, Can Your Employee Legally Work in the United States? Employment taxes Need to pay, Do You Need To Pay Employment Taxes? Payment options, Payment option for business employers. Form 1040 for 2011 tax year Tax returns, Business employment tax returns. Form 1040 for 2011 tax year Estimated tax, paying, Paying estimated tax. Form 1040 for 2011 tax year F Federal income tax withholding, increasing (see How to increase withholding) Federal unemployment (FUTA) tax, Federal Unemployment (FUTA) Tax Form 1040-ES, Paying estimated tax. Form 1040 for 2011 tax year 940, Business employment tax returns. Form 1040 for 2011 tax year 941, Business employment tax returns. Form 1040 for 2011 tax year 943, Business employment tax returns. Form 1040 for 2011 tax year 944, Business employment tax returns. Form 1040 for 2011 tax year I-9, Can Your Employee Legally Work in the United States? M-274, Can Your Employee Legally Work in the United States? SS-4, Employer identification number (EIN). Form 1040 for 2011 tax year SS-5, Employee's social security number. Form 1040 for 2011 tax year W-2, Notice about the EIC. Form 1040 for 2011 tax year , Form W-2. Form 1040 for 2011 tax year W-4, Do You Need To Withhold Federal Income Tax?, Asking for more federal income tax withholding. Form 1040 for 2011 tax year W-4P, Asking for more federal income tax withholding. Form 1040 for 2011 tax year Forms you must file, What Forms Must You File? Free tax services, Free help with your tax return. Form 1040 for 2011 tax year FUTA (see Federal Unemployment (FUTA)Tax) H Handbook for Employers, Can Your Employee Legally Work in the United States? Health aides (see Household employee) Help (see Tax help) House cleaning workers (see Household employee) Household employee, Do You Have a Household Employee? Housekeepers (see Household employee) How to increase withholding, Asking for more federal income tax withholding. Form 1040 for 2011 tax year How to pay estimated tax, Paying estimated tax. Form 1040 for 2011 tax year I Income tax withholding, increasing (see How to increase withholding) L Legal employee, Can Your Employee Legally Work in the United States? M Maids (see Household employee) Medicare (see Social security and Medicare taxes) N Nannies (see Household employee) Nonemployees, Workers who are not your employees. Form 1040 for 2011 tax year Nurses, private (see Household employee) P Publications (see Tax help) R Records you must keep, What Records Must You Keep? S Schedule H (Form 1040), How Do You Make Tax Payments?, Schedule H. Form 1040 for 2011 tax year Self-employed workers (see Nonemployees) Social security and Medicare Taxes, Social Security and Medicare Taxes Wages, Social security and Medicare wages. Form 1040 for 2011 tax year Social security number, employee's, Employee's social security number. Form 1040 for 2011 tax year State Disability payments, State disability payments treated as wages. Form 1040 for 2011 tax year Employment taxes, State employment taxes. Form 1040 for 2011 tax year Suggestions for publication, Comments and suggestions. Form 1040 for 2011 tax year T Tax credits Child and dependent care expenses, Can You Claim a Credit for Child and Dependent Care Expenses? Earned income, What Do You Need To Know About the Earned Income Credit? FUTA, Credit for 2013. Form 1040 for 2011 tax year Tax help, How To Get Tax Help Taxes How to make payments, How Do You Make Tax Payments? Medicare, Social Security and Medicare Taxes Social security, Social Security and Medicare Taxes U Unemployment taxes Federal, Federal Unemployment (FUTA) Tax State, State employment taxes. Form 1040 for 2011 tax year USCIS website, Can Your Employee Legally Work in the United States? W Wages Cash, Cash wages. Form 1040 for 2011 tax year FUTA, FUTA wages. Form 1040 for 2011 tax year Medicare, Social security and Medicare wages. Form 1040 for 2011 tax year Social security, Social security and Medicare wages. Form 1040 for 2011 tax year State disability payments, State disability payments treated as wages. Form 1040 for 2011 tax year Withholding Employee's share, Withholding the employee's share. Form 1040 for 2011 tax year Federal income tax, Do You Need To Withhold Federal Income Tax? How to increase, Asking for more federal income tax withholding. Form 1040 for 2011 tax year Wages, Wages. Form 1040 for 2011 tax year Y Yard workers (see Household employee) Prev  Up     Home   More Online Publications
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The Form 1040 For 2011 Tax Year

Form 1040 for 2011 tax year 18. Form 1040 for 2011 tax year   Appendix This appendix contains models of the certificates, waivers, reports, and statements discussed in Part One. Form 1040 for 2011 tax year Model Certificate A   STATEMENT OF SUBSEQUENT SELLER     1. Form 1040 for 2011 tax year                 Name, address, and employer identification number of seller in subsequent sale             2. Form 1040 for 2011 tax year                 Name, address, and employer identification number of the buyer in subsequent sale             3. Form 1040 for 2011 tax year         Date and location of subsequent sale             4. Form 1040 for 2011 tax year         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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year                   Signature and date signed                   Printed or typed name of person signing this report                   Title—   Model Certificate B   FIRST TAXPAYER'S REPORT   1. Form 1040 for 2011 tax year                     First Taxpayer's name, address and employer identification number     2. Form 1040 for 2011 tax year                     Name, address, and employer identification number of the buyer of the taxable fuel subject to tax     3. Form 1040 for 2011 tax year           Date and location of removal, entry, or sale       4. Form 1040 for 2011 tax year           Volume and type of taxable fuel removed, entered or sold     5. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year             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. Form 1040 for 2011 tax year                 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. Form 1040 for 2011 tax year                       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. Form 1040 for 2011 tax year )                 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. Form 1040 for 2011 tax year       This certificate applies to the following (complete as applicable):       If this is a single purchase certificate, check here and enter:     1. Form 1040 for 2011 tax year Invoice or delivery ticket number       2. Form 1040 for 2011 tax year (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. Form 1040 for 2011 tax year Effective date       2. Form 1040 for 2011 tax year Expiration date       (period not to exceed 1 year after the effective date)       3. Form 1040 for 2011 tax year Type (or types) of gasoline blendstocks     4. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year         Buyer will provide a new certificate to the seller if any information in this certificate changes. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year 4081-4(b)(3) of the Manufacturers and Retailers Excise Tax Regulations. Form 1040 for 2011 tax year       Buyer understands that if Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's     right to provide a certificate. Form 1040 for 2011 tax year       Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. Form 1040 for 2011 tax year     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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year             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. Form 1040 for 2011 tax year )         (Buyer) certifies the following under penalties of perjury:       Name of buyer         Buyer is a registered feedstock user with registration number . Form 1040 for 2011 tax year Buyer's registration has not been revoked     or suspended. Form 1040 for 2011 tax year         The kerosene to which this certificate applies will be used by Buyer for a feedstock purpose. Form 1040 for 2011 tax year                 This certificate applies to percent of Buyer's purchases from (name, address, and employer     identification number of seller) as follows (complete as applicable):       1. Form 1040 for 2011 tax year A single purchase on invoice or delivery ticket number . Form 1040 for 2011 tax year                 2. Form 1040 for 2011 tax year All purchases between (effective date) and (expiration date) (period not to exceed     one year after the effective date) under account or order number(s) . Form 1040 for 2011 tax year If this certificate applies only to Buyer's     purchases for certain locations, check here and list the locations. Form 1040 for 2011 tax year                                   If Buyer sells the kerosene to which this certificate relates, Buyer will be liable for tax on that sale. Form 1040 for 2011 tax year                 Buyer will provide a new certificate to the seller if any information in this certificate changes. Form 1040 for 2011 tax year                 If Buyer violates the terms of this certificate, the Internal Revenue Service may revoke the Buyer's registration. Form 1040 for 2011 tax year                 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. Form 1040 for 2011 tax year             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. Form 1040 for 2011 tax year )                                         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. Form 1040 for 2011 tax year       This certificate applies to the following (complete as applicable):               If this is a single purchase certificate, check here and enter:       1. Form 1040 for 2011 tax year Invoice or delivery ticket number       2. Form 1040 for 2011 tax year (Gasoline gallon equivalents)       If this is a certificate covering all purchases under a specified account or order number, check here and enter:         1. Form 1040 for 2011 tax year Effective date         2. Form 1040 for 2011 tax year Expiration date         (period not to exceed 1 year after the effective date)         3. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year       Buyer will provide a new certificate to the seller if any information in this certificate changes. Form 1040 for 2011 tax year       Buyer understands that if Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's     right to provide a certificate. Form 1040 for 2011 tax year       Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. Form 1040 for 2011 tax year     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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year             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. Form 1040 for 2011 tax year )           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). Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year Buyer's registration has not been suspended or revoked by the Internal Revenue Service. Form 1040 for 2011 tax year       This certificate applies to the following (complete as applicable):     This is a single purchase certificate:       1. Form 1040 for 2011 tax year Invoice or delivery ticket number       2. Form 1040 for 2011 tax year Number of gallons     This is a certificate covering all purchases under a specified account or order number:       1. Form 1040 for 2011 tax year Effective date       2. Form 1040 for 2011 tax year Expiration date (period not to exceed 1 year after the effective date)       3. Form 1040 for 2011 tax year Buyer's account number       Buyer agrees to provide the person liable for tax with a new certificate if any information in this certificate changes. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       Buyer understands that it must be prepared to establish by satisfactory evidence the purpose for which the     fuel purchased under this certificate was used. Form 1040 for 2011 tax year     Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn. Form 1040 for 2011 tax year     If Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's right to provide a certificate. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )               Name, Address, and Employer Identification Number of Ultimate Vendor     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. Form 1040 for 2011 tax year The kerosene to which this waiver relates is purchased for — (check one):       1. Form 1040 for 2011 tax year □ Use on a farm for farming purposes,       2. Form 1040 for 2011 tax year □ Use in foreign trade (reciprocal benefits required for foreign registered airlines),       3. Form 1040 for 2011 tax year □ Use in certain helicopter and fixed-wing air ambulance uses,       4. Form 1040 for 2011 tax year □ The exclusive use of a qualified blood collector organization,       5. Form 1040 for 2011 tax year □ The exclusive use of a nonprofit educational organization,       6. Form 1040 for 2011 tax year □ Use in an aircraft owned by an aircraft museum,       7. Form 1040 for 2011 tax year □ Use in military aircraft, or       8. Form 1040 for 2011 tax year □ Use in commercial aviation (other than foreign trade). Form 1040 for 2011 tax year     B. Form 1040 for 2011 tax year This waiver applies to the following (complete as applicable):       This is a single purchase waiver:           1. Form 1040 for 2011 tax year Invoice or delivery ticket number           2. Form 1040 for 2011 tax year Number of gallons       This is a waiver covering all purchases under a specified account or order number:           1. Form 1040 for 2011 tax year Effective date           2. Form 1040 for 2011 tax year Expiration date (period not to exceed 1 year after the effective date)           3. Form 1040 for 2011 tax year Buyer's account number       Buyer will provide a new waiver to the vendor if any information in this waiver changes. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )                       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. Form 1040 for 2011 tax year       This certificate applies to the following (complete as applicable):     This is a single purchase certificate:       1. Form 1040 for 2011 tax year Invoice or delivery ticket number       2. Form 1040 for 2011 tax year Number of gallons     This is a certificate covering all purchases under a specified account or order number:       1. Form 1040 for 2011 tax year Effective date       2. Form 1040 for 2011 tax year Expiration date (period not to exceed 1 year after the effective date)       3. Form 1040 for 2011 tax year Buyer's account number       Buyer will provide a new certificate to the vendor if any information in this certificate changes. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )                       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. Form 1040 for 2011 tax year       This waiver applies to the following (complete as applicable):     This is a single purchase waiver:       1. Form 1040 for 2011 tax year Invoice or delivery ticket number       2. Form 1040 for 2011 tax year Number of gallons     This is a waiver covering all purchases under a specified account or order number:       1. Form 1040 for 2011 tax year Effective date       2. Form 1040 for 2011 tax year Expiration date (period not to exceed 1 year after the effective date)       3. Form 1040 for 2011 tax year Buyer's account number       Buyer will provide a new waiver to the vendor if any information in this waiver changes. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )     The undersigned biodiesel producer (“Producer”) hereby certifies the following under penalties of perjury:   1. Form 1040 for 2011 tax year             Producer's name, address, and employer identification number (EIN)   2. Form 1040 for 2011 tax year             Name, address, and EIN of person buying the biodiesel from Producer   3. Form 1040 for 2011 tax year       Date and location of sale to buyer   4. Form 1040 for 2011 tax year This certificate applies to gallons of biodiesel. Form 1040 for 2011 tax year   5. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year             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. Form 1040 for 2011 tax year Original Certificate Identification Number (only in the case of certificates reissued to a reseller after return of the original certificate). Form 1040 for 2011 tax year       Producer is registered as a biodiesel producer with registration number . Form 1040 for 2011 tax year  Producer's registration has not been suspended or revoked by the Internal Revenue Service. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year S. Form 1040 for 2011 tax year C. Form 1040 for 2011 tax year 7545). Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )               Name, Address, and Employer Identification Number of Vendor     The undersigned buyer (“Buyer”) hereby certifies the following under penalties of perjury:     A. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year     B. Form 1040 for 2011 tax year This certificate applies to the following (complete as applicable):       1. Form 1040 for 2011 tax year   If this is a single purchase certificate, check here □ and enter:           a. Form 1040 for 2011 tax year Invoice or delivery ticket number           b. Form 1040 for 2011 tax year Number of gallons       2. Form 1040 for 2011 tax year   If this is a certificate covering all purchases under a specified account or order number, check here □  and enter:           a. Form 1040 for 2011 tax year Effective date           b. Form 1040 for 2011 tax year Expiration date   (period not to exceed 1 year after effective date)           c. Form 1040 for 2011 tax year Buyer's account or order number     ▪ Buyer will provide a new certificate to the vendor if any information in this certificate changes. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )               Name, Address, and Employer Identification Number of Ultimate Vendor     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. Form 1040 for 2011 tax year The kerosene to which this certificate relates is purchased for a nonexempt use in noncommercial aviation. Form 1040 for 2011 tax year     B. Form 1040 for 2011 tax year This certificate applies to the following (complete as applicable):       1. Form 1040 for 2011 tax year   If this is a single purchase certificate, check here □ and enter:           a. Form 1040 for 2011 tax year Invoice or delivery ticket number           b. Form 1040 for 2011 tax year Number of gallons       2. Form 1040 for 2011 tax year   This is a certificate covering all purchases under a specified account or order number:           a. Form 1040 for 2011 tax year Effective date           b. Form 1040 for 2011 tax year Expiration date   (period not to exceed 1 year after effective date)           c. Form 1040 for 2011 tax year Buyer's account number     ▪ Buyer will provide a new certificate to the vendor if any information in this certificate changes. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )               Name, Address, and Employer Identification Number of Credit Card Issuer. Form 1040 for 2011 tax year     The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under penalties of perjury:     A. Form 1040 for 2011 tax year Buyer will use the taxable fuel to which this certificate relates for the exclusive use of a state; or     B. Form 1040 for 2011 tax year Buyer will use the gasoline to which this certificate relates for the exclusive use of a nonprofit educational organization. Form 1040 for 2011 tax year     C. Form 1040 for 2011 tax year This certificate applies to all purchases made with the credit card identified below during the period specified:           a. Form 1040 for 2011 tax year Effective date of certificate           b. Form 1040 for 2011 tax year Expiration date of certificate   (period not to exceed 2 years after effective date)           c. Form 1040 for 2011 tax year Buyer's account number     ▪ Buyer will provide a new certificate to the credit card issuer if any information in this certificate changes. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year     ▪ 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. Form 1040 for 2011 tax year           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. Form 1040 for 2011 tax year )     The undersigned biodiesel producer (“Reseller”) hereby certifies the following under penalties of perjury:   1. Form 1040 for 2011 tax year                   Reseller's name, address, and employer identification number (EIN)   2. Form 1040 for 2011 tax year                   Name, address, and EIN of Reseller's buyer   3. Form 1040 for 2011 tax year       Date and location of sale to buyer   4. Form 1040 for 2011 tax year Volume of biodiesel sold   5. Form 1040 for 2011 tax year 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. Form 1040 for 2011 tax year       Reseller has not been notified by the Internal Revenue Service that its right to provide a certificate or statement has been withdrawn. Form 1040 for 2011 tax year       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. Form 1040 for 2011 tax year           Printed or typed name of person signing this certificate           Title of person signing           Signature and date signed   Prev  Up  Next   Home   More Online Publications