Form 1363 - Export Exemption Certificate Form

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1363

Export Exemption Certificates

OMB No. 1545-0685

Form

Check the appropriate box.

(Rev. December 2009)

Tax on Amount Paid for Transportation of Property by Air

Individual Exemption

Department of the Treasury

(Section 4271 of the Internal Revenue Code)

Blanket Exemption

Internal Revenue Service

Name (shipper or other on whom the tax is imposed)

Taxpayer identification number

Address (number and street)

For blanket approval, date of letter granting permission:

City, state, and ZIP code

Property shipped

Commodity

Weight

Name and address of carrier

Transportation charges

Date shipped

Point of origin

Port of exportation

from point of orgin

of shipment

Date paid

Amount paid

Under penalties of perjury, I declare that the shipment described above is made under a contract, order, or other written evidence of intention to export that was

dated earlier than delivery of the shipment to the carrier, and is to be exported to a foreign destination or shipped to a United States possession, and that I will pay

the carrier any tax due in case the property is not so exported or shipped. (See Suspension of Tax Liability on page 2.)

Signature

Title

Date

1363

For Privacy Act and Paperwork Reduction Act Notice, see back of form.

Cat. No. 49953S

Form

(Rev. 12-2009)