Colored Fuel Certification (Page 2 of 2) in pdf

CoLoUrEd FUEL

I am purchasing coloured fuel onLY for the following authorized uses (check (

) all intended uses):



a ship

a commercial motor vehicle (other than a pick-up truck)

when used off highway for transporting drilling rigs,

a locomotive

equipment and supplies, fuel, water, well-servicing

equipment/supplies, geophysical and seismic

tractor used off highway

equipment/supplies for persons actively engaged in

exploring or drilling for petroleum and natural gas

any of the following industrial machines when used

off highway:

farm vehicles that have a farm licence plate (also known

• any machine equipped

• fork-lifts

as an “a” or “g” plate) when operated for farm purposes

with caterpillar tracks

• front-end loaders

on a highway by, or on behalf of, a farmer

• earth compactors

• lumber carriers

• graders

a tractor when used on a highway for, or by, a farmer for

• bulldozers

• grass mowers

the farmer's farm

• shovels

• rollers

• backhoes

a motor vehicle used off highway by the logging

• skidders

• crushers

industry, such as:

• trucks used for hauling logs or lumber

a stationary or portable engine (for example, a

• crew crummies or buses used for the transportation

generator or a portable sawmill)

of company employees, contractors or agents of the

company, or employees of the contractors and agents

a road building machine (for example, an asphalt paving

• fire trucks used as fire trucks

machine, a self-propelled compressor) used within a

• ambulances used as ambulances

highway project area, or used by, or for, the government

for constructing or repairing government maintained roads

a motor vehicle used off highway by the mining

(including forestry and mining roads on Crown land)

industry in a mineral/mining operation, such as:

• trucks used for transporting minerals

a motor vehicle that is not licensed to operate on a

• crew crummies or buses used for the transportation

highway, including unlicensed snowmobiles and

of company employees, contractors or agents of the

all-terrain vehicles (aTVs)

company, or employees of the contractors and agents

• fire trucks used as fire trucks

• ambulances used as ambulances

MArINE dIEsEL ANd LoCoMoTIVE FUEL

I am purchasing (check (

) if applicable):



marine diesel for use in a ship

locomotive fuel for use in a locomotive or other vehicle run on rails

CErTIFICATIoN

By signing this form, I certify that I will use fuel for the authorized use(s) identified above.

I acknowledge that if:

• I purchase or use coloured fuel for a purpose that is not authorized under the Motor Fuel Tax Act, I must pay tax in

accordance with section 15(3) of the Motor Fuel Tax Act and I may be subject to penalties equal to the greater of:

three times the tax that would have been payable if the fuel had not been coloured, and

■

up to $1,000 per day per vehicle.

■

• I make a false statement on a form required under the Motor Fuel Tax Act, I may be subject to a fine of up to

$10,000 and/or imprisonment for up to two years.

FuLL LegaL name oF InDIVIDuaL SIgnIng Form

ComPanY name

(if applicable)

aCCounT numBer

– For Seller's

use only (if applicable)

(include street or PO box, city, province and postal code)

maILIng aDDreSS

TeLePhone numBer

(

)

SIgnaTure

DaTe SIgneD

YYYY / MM / DD

Page 2

FIN 430 Rev. 2015 / 5 / 5

Colored Fuel Certification Page 2

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