Form 5004 - Motor Fuel Refund Claim - Arizona Department Of Revenue
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1Arizona Department of Revenue
ARIZONA FORM
5004
Transaction Privilege and Use Tax
Used Oil Burner Exemption Certifi cate
Effective July 21, 1997
This exemption Certifi cate is prescribed by the Department of Revenue pursuant to A.R.S. § 42-5009
This Certifi cate is to be completed by the purchaser and furnished to the vendor. The vendor shall retain this Certifi cate.
Incomplete Certifi cates are not considered to be accepted in good faith.
Information
Information
Arizona Transaction Privilege Tax License Number
Purchaser’s Business Name and Address
TIN
Other Tax License Number
Other State/County
If no license number, provide reason:
Used Oil Permit No.
Used Oil Fuel Permit No.
Precise Nature of Business
Check Applicable Box:
Single Purchase Certifi cate
Period:
Through
Date of Purchase:
(If period box is checked, show the date of the fi rst purchase.)
If the Period box is checked, this Certifi cate is in force for the stated period, unless canceled by the purchaser or the vendor.
Exemption
Exemption
This Certifi cate is only for use by used oil burners or used oil fuel burners having a permit to burn used oil or used oil fuel when purchasing alternative
fuels. Alternative fuels are defi ned in ARS § 1-215 as liquefi ed petroleum gas, natural gas, hydrogen, a blend of hydrogen with liquefi ed petroleum
or, natural gas, alcohol fuel that contain not less than eighty-fi ve percent alcohol by volume, electricity or solar energy.
Certifi cate
Certifi cate
A seller that has reason to believe that the certifi cate is not accurate, complete or applicable to the transaction,
A seller that has reason to believe that the certifi cate is not accurate, complete or applicable to the transaction,
may not accept the certifi cate in good faith and the seller will not be relieved of the burden of proving entitlement
may not accept the certifi cate in good faith and the seller will not be relieved of the burden of proving entitlement
to the exemption. A seller that accepts a certifi cate in good faith will be relieved of the burden of proof and the
to the exemption. A seller that accepts a certifi cate in good faith will be relieved of the burden of proof and the
purchaser may be required to establish the accuracy of the claimed exemption. If the purchaser cannot establish
purchaser may be required to establish the accuracy of the claimed exemption. If the purchaser cannot establish
the accuracy and completeness of the information provided in the certifi cate, the purchaser is liable for an amount
the accuracy and completeness of the information provided in the certifi cate, the purchaser is liable for an amount
equal to the transaction privilege tax, penalty and interest which the seller would have been required to pay if the
equal to the transaction privilege tax, penalty and interest which the seller would have been required to pay if the
seller had not accepted the certifi cate. Misuse of this Certifi cate will subject the purchaser to payment of the ARS
seller had not accepted the certifi cate. Misuse of this Certifi cate will subject the purchaser to payment of the ARS
§ 42-5009 amount equal to any tax, penalty or interest. Willful misuse of this Certifi cate will subject the purchaser
§ 42-5009 amount equal to any tax, penalty or interest. Willful misuse of this Certifi cate will subject the purchaser
to criminal penalties of a felony pursuant to ARS § 42-1127.B.2.
to criminal penalties of a felony pursuant to ARS § 42-1127.B.2.
I, (print full name) ______________________________________, hereby certify that these purchases are exempt from
I, (print full name) ______________________________________, hereby certify that these purchases are exempt from
Arizona transaction privilege tax and that the information on this Certifi cate is true, accurate and complete. Futher, if
Arizona transaction privilege tax and that the information on this Certifi cate is true, accurate and complete. Futher, if
purchasing as an agent, I certify that I have a duly executed written authorized to execute this Certifi cate on behalf of the
purchasing as an agent, I certify that I have a duly executed written authorized to execute this Certifi cate on behalf of the
purchaser named above.
purchaser named above.
Signature of purchaser
Signature of purchaser __________________________________________________________________
__________________________________________________________________ Date
Date _________________________
_________________________
Title
Title _________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Exact reproductions and photocopies of this certifi cate are acceptable for use.
ADOR 20-2014 (4/02)
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