Form 13-79 - Exemption Certificate
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1Form 13-79
Revised 11-2013
Exemption Certificate
To support Buyer’s claim for an exemption from payment of Excise Tax levied under the Oklahoma Motor Fuel Tax Code.
(Vendor shall retain this document for not less than three (3) years)
______________________________________________
_______________________________________________
Name of Vendor
Vendor FEIN
_________________________________________________________________________________________________
Address of Vendor
_____________________________________________________
______________
__________________________
City
State
Zip Code
To be submitted to the following Supplier, CNG and/or LNG Wholesaler/Retailer:
Name: ________________________________________
FEIN: __________________________________________
This Exemption Applies to: (check only one type of entity)
Complete a separate Exemption Certificate for each exempt entity.
Public School District, FFA, 4-H Club for the Purpose
School District for Operation of Vehicles Used in
of Transporting Public School Children
Driver Training
Volunteer Fire Department
Rural Electric Cooperative
Rural Water and Sewer District
Rural Amublance Service District
Federally Recognized Indian Tribe
Agency or Instrumentality of the United States
City, County, or Town
State of Oklahoma, Underground Storage Fee
For Purchase of: (check which fuel type(s) apply)
Gasoline
Undyed Diesel
(Number of Gallons: _____________________ )
(Number of Gallons: _____________________ )
CNG
Petroleum Underground
(Number of Gallons: _____________________ )
Storage (Number of Gallons: ______________ )
LNG
(Number of Gallons: _____________________ )
Period in which the fuel was purchased: _______________________________________________________________
The BUYER understands that the fraudulent use of this certificate to obtain fuel without paying the tax levied will
result in BUYER paying the tax, with penalties and interest.
______________________________________________
_______________________________________________
Name of Buyer
Social Security Number or FEIN
_____________________________________________________________________ ( ______ ) _________________
Address of Buyer
Telephone Number of Buyer
_____________________________________________________
______________
__________________________
City
State
Zip Code
______________________________________________
_______________________________________________
Signature of Buyer
Date Signed
______________________________________________
_______________________________________________
Printed or Typed Name of Person Signing
Title of Person Signing
OMITTING Information required by Section 500.13 may result in the DISALLOWANCE of the Exemption.
Except for the ORIGINAL SIGNATURE, this form may be duplicated for future purchases.
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