New York State Department of Taxation and Finance
Certificate of Tax Exemption for a Qualified
Indian Nation or Tribe on Purchases of Motor
Fuel and Diesel Motor Fuel
To be completed by the nation or tribe and given to the seller, who must keep it for at least three years as explained in the instructions on
page 2 of this form.
This certificate may be used only by a qualified Indian nation or tribe purchasing products for official nation or tribal government use or
consumption and is not valid for purchases for resale or for purchases made and delivered off a qualified reservation. It is acceptable
as proof of exemption from state taxes on purchases of any or all of the products marked below, provided that all required criteria are met, all
required entries are completed, and a photocopy of the nation’s or tribe’s Form ST‑119, Exempt Organization Certificate, is attached. The copy
of Form ST‑119 must remain with this certificate.
Mark an X in any applicable boxes:
Diesel motor fuel
Part 1 — To be completed by nation or tribe (authorized representative)
Name of nation or tribe
(please print or type)
I, the undersigned, hereby certify that the nation or tribe named above is buying the products for official use and not for resale, and that the
nation or tribe holds a valid Form ST‑119, number EX ‑
, a copy of which is attached.
Signature of authorized representative of nation or tribe
Part 2 — To be completed by vendor
Name of vendor
(please print or type)
I, the vendor, hereby certify that the motor fuel or diesel motor fuel was sold in compliance with the terms of this certificate to the
above‑named Indian nation or tribe and was delivered directly to that nation or tribe on a qualified reservation.
Signature of vendor
By accepting this certificate, you are authorized to sell to the above‑named Indian nation or tribe motor fuel or diesel motor fuel free of state
taxes. This certificate, when properly completed, is your evidence that the purchaser is exempt from payment of the state taxes otherwise due
on a retail sale.
Failure to comply with the requirements outlined in this certificate may subject you to liability for tax and the imposition of civil and criminal
sanctions including penalty assessment, loss of product, and the suspension or revocation of any license or registration.