Fillable Form 3978 - Fuel Supplier Return (Page 3 of 5) in pdf

Form 3978 - Fuel Supplier Return Page 3

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Form 3978, Page 3

CERTIFICATIONS

I certify under penalty of perjury that I have examined this return and to the best of my knowledge and belief, it is true and complete. Suppliers of Gasoline/Ethanol

Blends/Aviation Fuel: I certify to the best of my knowledge and belief that any and all suppliers, wholesalers or retailers of gasoline or aviation fuel to whom gasoline or aviation

fuel, as defined by statute, was sold by this supplier during the period covered by this report, have been paid or credited as follows:

(A) To Suppliers/Wholesalers - 1.5% of the tax charged as allowed by statute to licensed suppliers of gasoline or aviation fuel.

(B) To Retailers - 1/3 of the 1.5% allowed by statute to licensed suppliers of gasoline or aviation fuel.

(C) No credits or payments have been extended during this report period as no sales of gasoline or aviation fuel have been

made to any supplier/wholesaler or retailer.

I authorize Treasury to discuss my return and attachments with my preparer.

Do not discuss with my preparer.

Authorized Signature

Printed Name

Telephone Number

Title

Date