Mf-209 Certificate Of Fuel Tax Exemption Exempt Sales Of Gasoline And Undyed Diesel Fuel
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MF-209: CERTIFICATE OF FUEL TAX EXEMPTION
EXEMPT SALES OF GASOLINE AND UNDYED DIESEL FUEL
Secs. 78.01(2) and (2m), Wis. Stats.
/
/
Effective Date:
/
/
Expiration Date:
Indicate below how the exempt fuel will be used. Customers must be prepared to substantiate exempt usage.
CHECK ALL BOXES THAT APPLY
Gasoline purchased for off-road use in mobile machinery and equipment and delivered directly into the customer’s
storage tank in an amount not less than 100 gallons. Describe use:
IF USED IN FARMING, CHECK THIS
BOX
Caution: Gasoline cannot be sold tax-exempt if it will be placed into the tank of a licensed motor vehicle (except an urban
mass transportation vehicle), snowmobile, recreational motorboat, or an all-terrain vehicle/utility terrain vehicle (unless
registered for private use).
Gasoline bought for use in aircraft by a general aviation fuel dealer or user licensed with the Wisconsin Department of
Revenue. Gasoline purchased by an aviation fuel dealer or user must be delivered directly into the dealer or user’s
storage tank in an amount not less than 100 gallons.
Gasoline and/or undyed diesel fuel purchased and used by the U. S. Government or one of its agencies.
Indicate the name of the agency:
The U. S. Government is also exempt from the
petroleum inspection fee (2¢ per gallon). The State of Wisconsin, local
municipalities in Wisconsin, and school districts are not the U. S. Government and should not check this box.
Gasoline and/or undyed diesel fuel purchased and used by common motor carriers for the urban mass transportation of
passengers.
Undyed diesel fuel purchased for use as heating oil.
Gasoline and/or undyed diesel fuel exported by a person licensed with the Wisconsin Department of Revenue to export
fuel.
Other - Describe use:
(For example: Undyed diesel fuel sold for use in trains; fuel sold to enrolled tribal members living on their own tribe’s
reservation or trust lands).
PENALTIES: Any person who provides false or fictitious information on the exemption certificate or uses the fuel purchased tax-exempt in a man-
ner not stated on the exemption certificate may be subject to tax, interest, penalties and fined not more than $500 or imprisoned not more than 6
months or both (sec. 78.73(1), Wis. Stats.).
Name of Customer (print or type)
Federal Employer ID No. or Social Security No.(if sole proprietor)
Zip Code
Business Address (street, or rural route and box number)
City
State
Business Telephone
Title
(
)
Signature of Customer
Date Signed
Name of Supplier (please print)
Address of Supplier
NEW HORIZONS SUPPLY COOPERATIVE
1775 4TH STREET, FENNIMORE, WI 53809
Signature of Supplier
Date Signed
MF-209 (R. 5-14)
Wisconsin Department of Revenue
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