Form 06-352 - End User Signed Statement For Purchasing Tax-Free Dyed Diesel Fuel
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106-352
(Rev.3-06/7)
TEXAS END USER SIGNED STATEMENT
FOR PURCHASING TAX-FREE
DYED DIESEL FUEL
Selling supplier
or distributor:
Address:
Purchasing entity name
End user signed statement number
Address
Beginning effective date
Taxpayer number
If the purchaser is a division of a corporation, give the name and address of the parent corporation, not the division D.B.A. name.
Parent corporation name:
Address:
PLEASE READ CAREFULLY BEFORE SIGNING
1. Will you use any of this diesel fuel in a motor vehicle on public highways, streets or roads?
YES
NO
2. Will you resell any of this diesel fuel?
YES
NO
3. Will you make purchases in excess of 7,400 gallons in a single
delivery or more than 10,000 gallons in total deliveries per month?
YES
NO
If any answer is "YES," you may not legally sign this statement.
EXCEPTION: A purchaser using an End User Signed Statement Number to purchase dyed diesel fuel for exclusive use in oil or gas production must
also furnish a Letter of Exception issued by the Comptroller to authorize the purchase of up to 25,000 gallons per month.
NOTE: THIS IS YOUR MASTER COPY. PLEASE RETAIN IN YOUR FILES AND MAKE COPIES AS NEEDED.
I DECLARE THAT:
none of the dyed diesel fuel purchased on this signed statement will be used on public highways, streets, or roads;
all of the dyed diesel fuel purchased on this signed statement will be consumed by the purchaser in Texas and will
not be resold; and
none of the dyed diesel fuel purchased on this signed statement will be delivered or permitted to be delivered into the
fuel supply tanks of motor vehicles operating on public highways, streets, or roads in this state.
I am aware that certain fines and criminal penalties are provided by law for giving a false diesel fuel signed statement.
Name of purchaser (Type or print)
By:
Purchaser or authorized representative (Type or print)
Signature of authorized representative
For information, call 1-800-252-1383, toll free nationwide.
The local number in Austin is 512/463-4600.
Date
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