Form 2992 - Fuel Tax Exemption Certificate - Sales To U.s. Government - 2014

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Missouri Department of Revenue

Form

Fuel Tax Exemption Certificate

2992

Sales to U.S. Government

Fuel retailers in Missouri making sales to the U.S. Government may make such sales without charging fuel tax if the

retailer has obtained a signed exemption certificate. This certificate must be maintained in the retailer’s files and must be

updated every three years.

Seller’s Name

Federal Employer Identification or Social Security Number

Address

City

State

Zip Code

Telephone Number

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

Purchaser’s Name

Federal Employer Identification or Social Security Number

Address

City

State

Zip Code

Telephone Number

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

Motor Fuel Sold To U.S. Government

Exempt Use

Government Agency Name

This Exemption is for: (select one)

All motor fuel purchased

__________________ Gallons

I hereby certify, under penalty of perjury, that the motor fuel purchased will be used in the exempt manner stated above and defined by the

statute quoted below. The invoice or sales slip for each individual purchase claimed under this exemption certificate will be signed and dated

and such exemption will be updated every three years with the retailer.

I further certify under penalty of perjury that if any of the motor fuel on said invoice or sales slip is not used as certified above, which will make

such fuel subject to the motor fuel tax, I will so notify the seller and pay the tax thereon. Should I not so notify the seller, then I am liable for

tax, penalty and interest on such purchase, pursuant to the provisions of

Chapter 142, RSMo.

Printed Name of Authorized Purchaser or Purchaser’s Agent

Title

Signature

Date (MM/DD/YYYY)

___ ___ /___ ___ /___ ___ ___ ___

This exemption certificate must be completed and maintained in the retailer’s files to substantiate sales made to the U.S.

Government.

Missouri law,

Section 142.815.2(3), RSMo,