FT‑1021‑A
New York State Department of Taxation and Finance
Certification for Purchases of
(6/12)
Non‑Highway Diesel Motor Fuel or
Residual Petroleum Product by
Certain Exempt Organizations
This certificate must be completed by the purchaser and given to the seller
.
(see instructions)
Type or print
Name of purchaser
Name of seller
Address
Address
(number and street)
(number and street)
City
State
ZIP code
City
State
ZIP code
Exempt organization number
EIN (mark an X in the appropriate box(es); enter EIN)
(from Form ST-119)
Distributor of diesel motor fuel
Federal employer identification number (EIN)
Retailer of non-highway diesel motor fuel only
Residual petroleum product business
Mark an X in the applicable box:
Single‑purchase certification
Blanket certification
Unless this is marked above as a Single-purchase certification, it will be considered part of any order given to the seller by the
purchaser and will remain in force until revoked by written notice. It covers purchases of the specific product marked below. Use a
separate Form FT‑1021‑A for each product.
I am purchasing
:
(mark an X in box 1 or 2)
1
Non‑highway diesel motor fuel
(complete worksheet below)
2
Residual petroleum product
(do not complete worksheet; exempt from petroleum business tax and state and local sales taxes).
No excise tax is imposed on residual petroleum product.
Fuel use percentage worksheet
Mark an X in one or more boxes and, if applicable, indicate the percentage. You must be able to substantiate the percentage of fuel
used for each purpose. The percentages must total 100%.
This fuel will be used for:
% Residential heating purposes (exempt from excise tax, petroleum business tax, and state and local sales taxes).
% Nonresidential heating purposes, and the purchaser is an organization exempt under:
Section 1116(a)(4) (exempt from excise tax, petroleum business tax, and state and local sales taxes).
Section 1116(a)(5) (exempt from excise tax and petroleum business tax, but subject to state and local sales
taxes).
% Other purposes (explain)
For purposes other than heating, but for the organization’s exempt purposes (exempt from excise tax and petroleum business tax, but
subject to state and local sales taxes, unless otherwise exempt). Note: Fuel used on the public highways, purchased at a filling station,
delivered into a tank with a nozzle capable of fueling a motor vehicle, or not used for the organization’s exempt purposes, is subject to
excise tax, state and local sales taxes, and petroleum business tax at the highway diesel motor fuel rate, unless otherwise exempt.
Signature
I certify that the above statements are true and complete, and 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 New York State Tax Law sections 1812(c)(4), 1812-f(c)(4),
and 1817(m) and Penal Law section 210.45, 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