Form Ft-1012 - Manufacturing Certification For Diesel Motor Fuel And Residual Petroleum Product Form

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New York State Department of Taxation and Finance
FT-1012
Manufacturing Certification for Diesel Motor Fuel and
(7/03)
Residual Petroleum Product
Purchasers and sellers: Read the information on back and certifications carefully before giving or accepting this certificate.
Sellers: Your sales are subject to the applicable taxes on diesel motor fuel or residual petroleum product unless the purchaser gives you a
properly completed certification no later than 90 days after the delivery of the product sold. Keep the certificate for at least three years.
Purchasers: This form must be completed by the purchaser and given to the seller.
Please type or print
Name of seller
Name of purchaser
Street address
Street address
City
State
ZIP code
City
State
ZIP code
Seller’s certificate of authority number
Purchaser’s certificate of authority number
. (Use a separate Form FT-1012 for each product type.)
Enter specific product type:
Single-purchase certificate — enter the invoice or delivery ticket number
, and the number of gallons
.
Blanket certificate — will be considered part of any order given to you and will remain in force until revoked by written notice. It
covers only purchases of the specific product type indicated above.
with a nozzle or other apparatus that can fuel a motor
Part I — Unenhanced diesel motor fuel
vehicle or be used on the highways of this state. (This
I certify that all (100%) of the unenhanced diesel motor
sale is subject to the petroleum business tax at the
fuel covered by this certificate is being delivered to the
commercial gallonage rate for diesel motor fuel but is
manufacturing site for use directly and exclusively in the
exempt from the diesel motor fuel tax and the New York
production of tangible personal property for sale, by
State and other local sales taxes.)
manufacturing, processing, or assembly, and will not
be consumed on the highways of this state. The fuel will
(d) I certify that
% of the fuel is to be used in the
not be delivered to a filling station or a tank equipped
production of gas, electricity (except if you are a
with a nozzle or other apparatus that can fuel a motor
rate-regulated electric corporation using the fuel in
vehicle. (This sale is exempt from the diesel motor fuel
generators to produce electricity), refrigeration or steam
tax, the petroleum business tax, and the New York
for sale. The fuel will not be delivered to a filling station
State and local sales taxes.)
or a storage tank equipped with a nozzle or other
apparatus that can fuel a motor vehicle or be used on
Part II — Unenhanced diesel motor fuel
(If less than
the highways of this state. (This sale is subject to the
100% of the fuel is to be used for manufacturing as stated
petroleum business tax at the commercial gallonage
above, check this box and indicate the appropriate
rate for diesel motor fuel and, if delivered or used in
percentages (must total 100%) of use.)
New York City, the city of New York local sales tax, but
exempt from the diesel motor fuel tax and the New York
State and other local sales taxes.)
(a) I certify that
% of the fuel is to be used in the
production of tangible personal property for sale as
(e) I certify that
% of the fuel is to be used for
described above (must be supported by an engineering
residential heating purposes. (This sale is exempt from
study).
the petroleum business tax, the diesel motor fuel tax,
and the New York State sales tax but, if applicable,
(b) I certify that
% of the fuel is to be used for
subject to local sales tax.)
nonresidential (commercial) heating purposes. (This
sale is subject to the petroleum business tax at the
(f) I certify that
% of the fuel is to be used for
nonresidential heating rate for diesel motor fuel and the
any other purpose (except on the highways of this
New York State and local sales taxes, but exempt from
state) than that stated above. (This sale is subject to
the diesel motor fuel tax.)
the petroleum business tax at the automotive rate, the
diesel motor fuel tax, and the New York State and local
(c) I certify that
% of the fuel is to be used in the
sales taxes, unless a valid exemption document is
production of tangible personal property for sale by
completed and given to the supplier.)
refining, mining or extracting. The fuel will not be
delivered to a filling station or a storage tank equipped
Note: Kerosene is exempt from the petroleum business tax when sold by a petroleum business registered as a distributor of diesel motor
fuel or a retailer of heating oil only and the kerosene is not mixed or blended with other products, is not sold with any other petroleum product,
or is not sold or used to operate motor vehicles or delivered into a tank equipped with a nozzle.
I certify that the above statements are true and complete, and I make these statements with the knowledge that willfully issuing a false
or fraudulent certificate with the intent to evade tax is a misdemeanor under sections 1812(c)(4), 1812-f(c)(4), and 1817(m) of the
New York State Tax Law and section 210.45 of the Penal Law, punishable by a fine up to $10,000 for an individual or $20,000 for a
corporation. I also understand that the Tax Department is authorized to investigate the validity of exemptions claimed or the accuracy
of any information entered on this form.
Signature of purchaser or authorized representative
Title
Date

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