Publication 510 - Excise Taxes For 2005 - Department Of Treasury (Page 39 of 47) in pdf

Publication 510 - Excise Taxes For 2005 - Department Of Treasury Page 39

Model Certificate J

CERTIFICATE OF PERSON BUYING COMPRESSED NATURAL GAS (CNG) FOR A NONTAXABLE USE

(To support tax-free sales of CNG under section 4041 of the Internal Revenue Code.)

Name, address, and employer identification number of seller

(“Buyer”) certifies the following under penalties of perjury:

(Name of buyer)

The CNG to which this certificate relates will be used in a nontaxable use.

This certificate applies to the following (complete as applicable):

The kerosene to which this certificate applies will be used by Buyer for a feedstock purpose.

If this is a single purchase certificate, check here

and enter:

1. Invoice or delivery ticket number

(number of MCFs)

If this is a certificate covering all purchases under a specified account or order number, check here

and enter:

1. Effective date

2. Expiration date

(period not to exceed 1 year after the effective date)

3. Buyer account or order number

Buyer will not claim a credit or refund under section 6427 of the Internal Revenue Code for any CNG to which this certificate

relates.

Buyer will provide a new certificate to the seller if any information in this certificate changes.

Buyer understands that if Buyer violates the terms of this certificate, the Internal Revenue Service may withdraw Buyer’s

right to provide a certificate.

Buyer has not been notified by the Internal Revenue Service that its right to provide a certificate has been withdrawn.

In addition, the Internal Revenue Service has not notified Buyer that the right to provide a certificate has been withdrawn

from a purchaser to which Buyer sells CNG tax free.

Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making any fraudulent use

of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.

Printed or typed name of person signing

Title of person signing

Employer identification number

Address of Buyer

Signature and date signed

Page 39

Publication 510 - Excise Taxes For 2005 - Department Of Treasury Page 39