Form 4776 - Ultimate Vendor Certificate Sales To Federal Government Only Page 2
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1
2Instructions for Ultimate Vendor Certificate
Sales To Federal Government Only
General Instructions
This form is to be completed in order to obtain motor fuel without paying the tax for sale to the U.S. Federal Government or to obtain credit or
refund from the supplier on sales charged to a government fueling credit card.
Identifying Information
Ultimate Vendor Name, Address, Telephone and FEIN or Social Security Number: Enter the name and information for the Ultimate Vendor.
Sales Information
Enter the name of the federal government agency, date of sale, product type and the number of gallons purchased.
The certificate must be signed and dated by the ultimate vendor.
The certificate is passed up the distribution chain between the ultimate vendor and the supplier. Each intermediate vendor must endorse the
certificate, keeping a copy for themselves. The original certificate is to be retained by the supplier. As a condition for the supplier to obtain
credit on their monthly report, the supplier shall credit or refund the tax to the ultimate vendor, who made the sale to the purchasing entity.
If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov. You may also
access the department’s web site at to obtain this form.
MO 860-2845 (11-2006)
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Parent category: Financial