Form Mfa-4 - Export Certificate

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Division use only — DLN Stamp
Division use only — Date Stamp
Period
mm
yyyy
Pursuant to NJSA 54:39-101 et seq
10-2010
Export Certificate
MFA-4
Address
Issuer
Issuer ID #
City, State Zip
This document serves to certify to:
Seller
Seller ID #
that the purchases detailed on the attached on this form or on the attached Schedules were
made for immediate export. By issuing this form, this company agrees to make its records
available for audit.
name
address
Terminal of Origin
Terminal Operator
Terminal #
Gasoline
Diesel / Kerosene
LPG
Total
Destination
Exported
Exported
Exported
Exports
States
(in gallons)
Totals
Signator's Printed Name
Signator's Signature
Signator's Title
Date Signed

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