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FT-1001

New York State Department of Taxation and Finance

Exemption Certificate for Diesel Motor Fuel

(12/06)

Interdistributor Transactions

This certificate must be completed by the purchaser and the seller at the time of or prior to delivery; both must keep a copy for at least three

years after the date of the sale substantiated by this certificate.

Name of seller

Name of purchaser

Street address

City

State

ZIP code

City

State

ZIP code

Seller’s certificate of authority number

Purchaser’s certificate of authority number

Seller’s NYS distributor of diesel motor fuel registration number

Purchaser’s NYS fuel tax registration number

Specific product type

Purchaser’s NYS direct pay permit number

(see instructions)

Mark an X in the applicable box:

Single-purchase certificate — Enter the invoice or delivery ticket number

, and the number of

gallons

Blanket certificate — Completed Form FT-1001 will be considered part of any order given to you and will remain in force until revoked

by written notice to you.

Certification of purchaser —

If purchasing unenhanced diesel motor fuel, complete Part 1 or 2. If purchasing dyed diesel motor

fuel using a direct pay permit, complete Part 3

Part 1 — I certify that I am a

distributor of diesel motor fuel or a

retailer of heating oil only purchasing unenhanced diesel

product, and the sale to me is not a sale at retail or a sale that involves a delivery at a filling station or into a repository equipped with

a hose or other apparatus for dispensing diesel motor fuel into the tank of a motor vehicle. (Exempt from diesel motor fuel tax, the

petroleum business tax, and prepaid sales tax.)

Part 2 — I certify that I am a distributor of kero-jet fuel only, purchasing kero-jet fuel exclusively for sale at retail for delivery directly

into the fuel tank of an airplane at my fixed base of operations at an airport in this state. (Exempt from diesel motor fuel tax and

petroleum business tax; subject to prepaid sales tax.)

Part 3 — I certify that

• I am currently registered as a distributor of diesel motor fuel primarily engaged in the retail heating oil business;

• I hold a valid direct pay permit for dyed diesel motor fuel that has not been suspended or revoked; and

• I will only sell the dyed diesel motor fuel to consumers for residential or nonresidential heating purposes. However, if I am purchasing

dyed diesel motor fuel directly from the importer and dyer of the fuel, I may sell the fuel to another holder of a valid direct pay permit.

I further certify that the sale to me is not a sale at retail or a sale that involves delivery into a repository equipped with a hose or other

apparatus capable of being used to dispense fuel into the fuel tank of a motor vehicle. (Exempt from diesel motor fuel tax, petroleum

business tax, and prepaid sales tax.)

Note to seller and purchaser: If the seller is not the importer and dyer of the dyed diesel motor fuel, the seller must attach to the invoice a

copy of the invoice given by the importer. If the attachment is on the invoice, the second purchaser of the dyed diesel motor fuel cannot sell

the dyed diesel motor fuel for resale, but must sell the fuel to consumers for heating purposes.

Signature of purchaser —

I certify that the information on this certificate is complete and accurate in all material respects, and that my

registration as a distributor of diesel motor fuel and my direct pay permit (if purchasing dyed diesel motor fuel) as indicated above are current

and have not been suspended or canceled. I make these statements with the knowledge that willfully issuing a false or fraudulent certificate

with the intent to evade tax is a misdemeanor under sections 1812(c)(4), 1812-f(c)(4), and 1817(m) of the New York State Tax Law and

section 210.45 of the Penal Law, punishable by a fine up to $10,000 for an individual or $20,000 or more for a corporation. I also understand

that the Tax Department is authorized to investigate the validity of exemptions claimed or the accuracy of any information entered on this form.

Signature of purchaser or authorized representative

Title

Date

Form Ft-1001 - Exemption Certificate For Diesel Motor Fuel Interdistributor Transactions - 2006

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