Publication 510 - Excise Taxes For 2005 - Department Of Treasury Page 42
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47Model Certificate M
CERTIFICATE FOR STATE USE OR NONPROFIT EDUCATIONAL
ORGANIZATION USE
To support vendor’s claim for a credit or payment under § 6416(a)(4) of the Internal Revenue Code.
Name, address, and employer identification number of ultimate vendor
The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under the penalties of perjury:
Buyer will use the gasoline or aviation gasoline to which this certificate relates (check one):
For the exclusive use of a state; or
For the exclusive use of a nonprofit educational organization.
This certificate applies to the following (complete as applicable):
This is a single purchase certificate:
1.
Invoice or delivery ticket number
2.
Number of gallons
This is a certificate covering all purchases under a specified account or order number:
1. Effective date
2. Expiration date
(period not to exceed 1 year after the effective date)
3. Buyer account number
Buyer will provide a new certificate to the vendor if any information in this certificate changes.
Buyer understands that by signing this certificate, Buyer gives up its right to claim any credit or payment for
the gasoline or aviation gasoline to which this certificate relates.
Buyer acknowledges that it has not and will not claim any credit or payment for the gasoline or aviation
gasoline to which this certificate relates.
Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making such
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
Name of Buyer
Employer identification number
Address of Buyer
Signature and date signed
Page 42
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