Form 13-89 - Ultimate Vendor Certificate

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Form 13-89
Revised 11-2013
Ultimate Vendor Certificate
To support Vendor’s claim for a credit or payment under Section 500.13 of the Oklahoma Motor Fuel Tax Code.
(Vendor submit this document to Supplier, CNG and/or LNG Wholesaler/Retailer/Consumer)
The Ultimate Vendor hereby Certifies:
1. The the Ultimate Vendor sold motor fuel to the purchasing entity for the exempt purpose;
2. That the Ultimate Vendor has the necessary records to support the sale of the motor fuel, and;
3. That the Ultimate Vendor understands and agrees that the fraudulent use of the Certificate to obtain fuel without
paying the tax levied or paying a refund of the tax shall result in payment of the tax by the Ultimate Vendor with
penalties and interest as well as such other penalties provided by statute.
______________________________________________
_______________________________________________
Name of Vendor
Vendor FEIN
_____________________________________________________________________ ( ______ ) _________________
Address of Vendor
Telephone Number
_____________________________________________________
______________
__________________________
City
State
Zip Code
______________________________________________
_______________________________________________
Signature of Ultimate Vendor
Date Signed
______________________________________________
________________________________
_____________
Intermediate Vendor’s Name
Signature
Date
______________________________________________
________________________________
_____________
Intermediate Vendor’s Name
Signature
Date
Purchasing Entity:
______________________________________________
_______________________________________________
Name of Purchasing Entity
Purchasing Entity FEIN
Quantity of Exempt Motor Fuel Sold:
______________________________________________
Date of Sale
______________________________________________
_______________________________________________
Gallons of Exempt Gasoline Sold
Gasoline Tax Claimed
______________________________________________
_______________________________________________
Gallons of Exempt Diesel Sold
Deisel Tax Claimed
______________________________________________
_______________________________________________
Gallons of Exempt CNG Sold
CNG Tax Claimed
______________________________________________
_______________________________________________
Gallons of Exempt LNG Sold
LNG Tax Claimed
______________________________________________
_______________________________________________
Gallons of Dyed Diesel Sold
Underground Tank Storage Fee Claimed
To be Completed by Supplier and/or Wholesaler/Retailer/Consumer:
______________________________________________
_________________
___________________________
Total Amount Claimed
Name of Supplier, CNG and/or LNG Wholesaler/Retailer/Consumer
FEIN
_____________________________________________________________________ ( ______ ) _________________
Address of Supplier, CNG and/or LNG Wholesaler/Retailer/Consumer
Telephone Number
_____________________________________________________
______________
__________________________
City
State
Zip Code
I declare this claim is made under penalties of perjury and that the information contained in this document and any attachments is true and correct to the
best of my knowledge and belief.
Sign Here: ___________________________________________________
Date: ___________________________

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