Publication 510 - Excise Taxes - 2004 Page 38
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48Appendix B
This appendix contains models of the certificates, reports, and statements discussed earlier under Fuel Taxes.
Model Certificate A
FIRST TAXPAYER’S REPORT
1.
First Taxpayer’s name, address, and employer identification number
2.
Name, address, and employer identification number of the buyer of the taxable fuel subject to tax
3.
Date and location of removal, entry, or sale
4.
Volume and type of taxable fuel removed, entered, or sold
5.
Check type of taxable event:
Removal from refinery
Entry into United States
Bulk transfer from terminal by unregistered position holder
Bulk transfer not received at an approved terminal
Sale within the bulk transfer/terminal system
Removal at the terminal rack
Removal or sale by the blender
6.
Amount of federal excise tax paid on account of the removal, entry, or sale
The undersigned taxpayer (“Taxpayer”) has not received, and will not claim, a credit with respect to, or a refund of, the tax on the
taxable fuel to which this form relates.
Under penalties of perjury, Taxpayer declares that Taxpayer has examined this statement, including any accompanying schedules and
statements, and, to the best of Taxpayer’s knowledge and belief, they are true, correct and complete.
Signature and date signed
Printed or typed name of person signing this report
Title
Page 38
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