Form Avf-105 - Aviation Fuel Excise Tax Exemption Certificate
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1
2Indiana Department of Revenue
AVF-105
State Form 55314
Aviation Fuel Excise Tax Exemption Certifi cate
(R / 7-13)
Name of Purchaser _______________________________________________________________________________
Business Address _______________________ City ______________________ State ________ Zip ______________
Provide your Indiana Registered Retail Merchant
Certifi cate, TID, and LOC number, as shown on
your certifi cate ..................................................................
_________________________
____________
TID Number (10 digits)
LOC Number (3 digits)
If not registered with the Indiana Department of
Revenue, provide your state tax ID number
from another state ............................................................
_________________________
_________________
State ID Number
State of Issue
If you do not have either an Indiana TID number or another state ID number, you must provide one of the following:
Public transportation haulers operating under another carrier’s authority must enter their Social Security number or federal
identifi cation number on the State ID Number line.
□
□
Is this a
blanket purchase exemption or a
single purchase exemption? (check one)
Purchaser must indicate the type of exemption being claimed for this purchase. (check one):
□
United States federal government - show agency name _______________________________________________
Note: A U.S. government agency should enter its federal identification number (FID) in lieu of a state ID number.
□
The state of Indiana
□
The Indiana Air National Guard
□
Common carrier of passengers or freight
□
Sales for resale only
I hereby certify under the penalties of perjury that the aviation fuel purchased with this exemption certifi cate is to be placed
into the fuel supply tank of an aircraft.
I confi rm my understanding that the misuse (either negligent or intentional) and/or fraudulent use of this certifi cate may
subject both me personally and/or the business entity I represent to the imposition of tax, interest, and civil and/or criminal
penalties.
Printed Name ____________________________________________
Title ________________________________
Signature of Purchaser ____________________________________
Date ________________________________
Email ________________________________________
Telephone Number _______________________________
The Indiana Department of Revenue may request verifi cation of registration in another state if you are an out-of-state
purchaser.
Seller must keep this certifi cate on fi le to support exempt sales.
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