(Date) ____________________, 19____
The undersigned signifies that he/she, or the
_______________________________
(Name of purchaser if other than undersigned)
of which the undersigned is
_______________________________
(Title)
holds Certificate of Registry No. __________
or has not registered because
_______________________________
(Brief statement of exception from registration relied upon)
delivered into a supply tank of the subject aircraft may be purchased free of tax because the fuel will be used
_______________________________
(Brief statement of tax-free use)
The undersigned understands that if the fuel is used otherwise than as stated above and for a purpose taxable under section 4041 of the Internal Revenue Code, the undersigned will be liable for the tax upon such use, and that the undersigned must be prepared to establish by satisfactory evidence the purpose for which the fuel purchased under this certificate was used.
The undersigned also understands that the fraudulent use of this certificate to secure exemption will subject the undersigned and all others making fraudulent use to a penalty equivalent to the amount of tax due on the sale of the fuel and, upon conviction, to a fine of not more than $10,000, or to imprisonment for not more than 5 years, or both, together with the costs of prosecution.
_______________________________
(Signature)
_______________________________
(Address)
26 C.F.R. §48.4041-11