Sd Eform-0856 V1 - Application For Motor Fuel Tax Exemption Motor Fuel Purchases By South Dakota Indian Tribes Page 2

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PART III. ACTIVITIES AND OPERATION INFORMATION
Physical location of the school itself_________________________________________________________
Yes
No
Is the school located within Indian Country?__________________________________________________
If yes, are the premises held in trust by the United States for the benefit of the tribe?___________________
Yes
No
Description of physical location of where the motor fuel is stored__________________________________
______________________________________________________________________________________
Yes
No
Does this organization purchase motor fuel in bulk which is then stored in fuel tanks?_________________
Are the fuel tanks where the fuel is being stored located on the school premises?_____________________
What is the motor fuel used in (i.e., equipment)?_______________________________________________
What vehicles is the motor fuel being consumed in?____________________________________________
______________________________________________________________________________________
For what purpose are the vehicles being used?_________________________________________________
Are any of the vehicles in which the motor fuel is consumed owned and licensed by the federal
government?_________________ If yes, please identify those vehicles and the license numbers
Yes
No
______________________________________________________________________________________
______________________________________________________________________________________
Description of funding for the school________________________________________________________
______________________________________________________________________________________
Is the funding provided by the Indian Self-Determination and Educational Assistance Act or any other
public funding?____________________ If yes, indicate what funding is received?___________________
Yes
No
______________________________________________________________________________________
I DECLARE under the penalties of perjury that I am authorized to sign this application on behalf of the
above organization and I have examined this application, including the accompanying statements, and to
the best of my knowledge it is true, correct and complete.
Signature
Title or Authority
Date
1.
PRINT FOR MAILING
CLEAR FORM

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