CERTIFICATE OF BUYER FOR PRODUCTION OF A COLD WEATHER BLEND (To support vendor's claim for a credit or payment under section 6427 of the Internal Revenue Code.)
__________(Buyer) certifies the following under penalties of perjury:
Name of buyer
The kerosene to which this certificate applies will be used by Buyer to produce a blend of kerosene and diesel fuel in an area described in a declaration of extreme cold and the blend will be sold for use or used for heating purposes.
This certificate applies to ____ percent of Buyer's purchase from __________ (name, address, and employer identification number of seller) on invoice or delivery ticket number ____.
If Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer's right to provide a certificate.
Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.
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.
__________________________________________
Printed or typed name of person signing.
__________________________________________
Title of person signing
__________________________________________
Employer identification number
__________________________________________
Address of Buyer
__________________________________________
Signature and date signed
26 C.F.R. §48.6427-11