Form Mft-13 - Export Certificate Page 2
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2MFT-13
(Sch. A)
SCHEDULE A
Period covered by this certificate:
Beginning ___________________
Ending__________________
Details of Export Sales (for use with blanket certificate)
Date of Sale
Date of Delivery
Type of Petroleum
Number of Gallons
Dollar Amount of Sale
INSTRUCTIONS FOR USE OF EXPORT CERTIFICATE
This form must be completed for each sale of motor fuels to a licensed exporter.
The exporter must list his name, license number, and address in the section marked buyer information.
In the event that the certificate is for a single sale, the purchaser will check the block marked single sale and
complete the line that follows. If the certificate covers multiple sales, which may extend over a period not
exceeding one year, the date of sale, date of delivery, type of petroleum, number of gallons, and dollar amount
must be entered on Schedule A for each included sale. Multiple sales may be entered on a single certificate
only if customer, product, source and destination of product are identical.
Buyer must complete and sign Certification of Buyer to include name of buyer, signature of buyer or corporate
officer, title of person signing certification and date of signature.
Buyer must complete the balance of the certificate and provide all requested information.
If the certificate is not for a single sale, NO SALES MAY BE INCLUDED IF ANY DETAIL OF A PARTICULAR
SALE DIFFERS FROM THE OTHER SALES AS LISTED UNDER DETAIL OF SALE.
Copies of this form and supporting documents must be retained by both the buyer and the seller for a period of
three years.
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