Form 06-710 - End User Agricultural Signed Statement For Purchasing Tax-Free Dyed Diesel Fuel

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06-710
(Rev.2-06/7)
TEXAS END USER AGRICULTURAL SIGNED STATEMENT
FOR PURCHASING TAX-FREE DYED DIESEL FUEL
Selling supplier
or distributor:
Address:
Purchasing entity name
End user agricultural 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 25,000 gallons in total deliveries per month?
YES
NO
If any answer is "YES," you may not legally sign this statement.
NOTE: THIS IS YOUR MASTER COPY. PLEASE RETAIN IN YOUR FILES AND MAKE COPIES AS NEEDED.
I DECLARE THAT:
all of the dyed diesel fuel purchased on this signed statement will be used exclusively in agricultural non-highway
equipment in Texas;
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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