CERTIFICATE OF FARMING USE OR STATE USE
(To support vendor's claim for a credit or payment under section 6427 of the Internal Revenue Code.)
_______________________________
_______________________________
Name, address, and employer identification number of vendor
The undersigned buyer ("Buyer") hereby certifies the following under penalties of perjury:
Buyer will use the diesel fuel or kerosene to which this certificate relates-(check one)
______ On a farm for farming purposes (as defined in § 48.6420-4(c) of the Manufacturers and Retailers Excise Tax Regulations) and Buyer is the owner, tenant, or operator of the farm on which the fuel will be used;
______ On a farm (as defined in § 48.6420-4(c) ) for any of the purposes described in paragraph (d) of that section (relating to cultivating, raising, or harvesting) and Buyer is a person that is not the owner, tenant, or operator of the farm on which the fuel will be used; or
______ For the exclusive use of a State or local government, or the District of Columbia.
This certificate applies to the following (complete as applicable):
If this is a single purchase certificate, check here ______ and enter:
1. Invoice or delivery ticket number ______
2. ______ (number of gallons)
If this is a certificate covering all purchases under a specified account or order number, check here ______ and enter:
1. Effective date ______
2. Expiration date ______ (period not to exceed 1 year after the effective date)
3. Buyer account or order number ______
Buyer will provide a new certificate to the vendor if any information in this certificate changes.
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 tax.
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
_______________________________
Name of Buyer
_______________________________
Employer identification number
_______________________________
Address of Buyer
_______________________________
Signature and date signed
26 C.F.R. §48.6427-9