Form 72a110 - Certification Of Motor Fuels Nonhighway Use printable pdf download

72A110 (04-11)

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

cERTiFicATiON OF MOTOR FUEls NONhighwAy UsE

See instructions on reverse side.

sEcTiON A

I hereby certify that motor fuels purchased from this date forward without payment of the Kentucky

motor fuels tax is used exclusively for nonhighway purposes. The nonhighway use of this fuel is indicated

below.

gasoline

(1)  Agricultural purposes (KRS 138.358(2))

___________________________________________

(Print) Kentucky Motor Fuels Tax Refund Permit Number

special Fuels

(2)  Personal residence (KRS 138.358(1))

___________________________________________

(Print) Purchaser's Driver's License Number

(3)  Agricultural purposes (KRS 138.358(2))

___________________________________________

(Print) Kentucky Motor Fuels Tax Refund Permit Number

(4)  Resident nonprofit religious, charitable or

educational organization, or state or local

government agency (KRS 138.358(3))

___________________________________________

(Print) Kentucky Sales and Use Tax Exempt Number

(5)  Rail locomotive power and unlicensed company

vehicles and equipment (KRS 138.240(2)(f))

___________________________________________

(Print) Kentucky Motor Fuels Tax Refund Permit Number

(6)  Other nonhighway use in unlicensed

vehicles and equipment (KRS 138.358(4))

___________________________________________

(Print) Kentucky Motor Fuels Tax Refund Permit Number

sEcTiON B (Please print each item)

Nonhighway use storage tank(s) located at:

_________ ___________________________________________

(List each tank separately by fuel type—

Tank

Street or Highway

Capacity

additional space provided on reverse for

purchasers with multiple tanks.)

___________________________________________

 Gasoline

 Special Fuels

City

State

ZIP Code

Exempt motor fuel purchased from:

_________________________________________

___________________________________________

Name of Kentucky Licensed Motor Fuels Dealer

Street or Highway

GL-

FL-

_________________________________________

___________________________________________

Kentucky Motor Fuels Dealer License Number

City

County

State

ZIP Code

sEcTiON c

I acknowledge that any exempt motor fuels used for any purpose other than provided in this certification may result

in imposition of applicable penalties provided by law. I understand that the individual or company for which this

certification is executed will be liable for applicable tax, penalty and interest on such fuel.

(Print) Name of Purchaser

Signature of Purchaser or Authorized

Company Representative

Date Signed

This certificate shall remain in full force and effect until or unless revoked in writing.

Form 72a110 - Certification Of Motor Fuels Nonhighway Use

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