Form 4776 - Ultimate Vendor Certificate Sales To Federal Government Only

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DLN

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300

4776

(573) 751-2611

TDD (800) 735-2966

ULTIMATE VENDOR CERTIFICATE SALES

(REV. 02-2011)

TO FEDERAL GOVERNMENT ONLY

ULTIMATE VENDOR NAME

TELEPHONE NUMBER

FEIN OR SOCIAL SECURITY NUMBER

(__ __ __) __ __ __ - __ __ __ __

___ ___ ___ ___ ___ ___ ___ ___ ___

ADDRESS

P.O. BOX

CITY

STATE

ZIP

__ __ __ __ __

PRODUCT CODE

065 — Gasoline

124 — Gasohol

142 — Kerosene

228 — Dyed Diesel Fuel

290 — Bio-Diesel – Dyed B100

123 — Alcohol

125 — Aviation Gasoline

072 — Dyed Kerosene

284 — Bio-Diesel – Undyed B100

122 — Blending Components

241 — Ethanol

130 — Jet Fuel

160 — Diesel Fuel

285 — Soy Oil

(Identify)

SALES INFORMATION

Federal Government Agency

Date of Sale

Product Type

Number of Gallons

__ __ / __ __ / __ __ __ __

I hereby certify, under penalties of perjury, that the motor fuel purchased was sold to an agency of the federal government for use by that agency. I further certify that I have the

necessary records to support the sale of the motor fuel.

I understand and agree that fraudulent use of this certificate to obtain motor fuel without paying the tax levied or receiving a refund of the tax whether for the ultimate vendor or

others, shall result in the ultimate vendor paying the tax with penalties and interest, as well as such other penalties provided for in Chapter 142, RSMo.

PRINT NAME

AUTHORIZED SIGNATURE OF ULTIMATE VENDOR

DATE

__ __ / __ __ / __ __ __ __

INTERMEDIATE VENDOR #1

FEIN

__ __ __ __ __ __ __ __ __

ADDRESS

CITY

STATE

ZIP

___ ___ ___ ___ ___