Publication 510 - Excise Taxes For 2005 - Department Of Treasury (Page 44 of 47) in pdf

Publication 510 - Excise Taxes For 2005 - Department Of Treasury Page 44

Model Certificate O

CERTIFICATE FOR BIODIESEL

(To support a claim under §§ 6426(c), 6427(e), and 40A of the Internal Revenue Code)

Name, address, and employer identification number of claimant.

The undersigned biodiesel producer (“Producer”) hereby certifies the following under penalties of perjury:

Producer certifies that the biodiesel to which this certificate relates is monoalkyl esters of long chain fatty

acids derived from plant or animal matter that meets the requirements of the American Society of Testing and Materials

D6751 and the registration requirements for fuels and fuel additives established by EPA under § 211 of the

Clean Air Act (42 U.S.C § 7545)

Producer certifies that the biodiesel to which this certificate relates is:

% Agri-biodiesel (derived solely from virgin oils, including esters derived from virgin vegetable oils from corn,

soybeans, sunflower seeds, cottonseeds, canola, crambe, rapeseeds, safflowers, flaxseeds, rice bran, and mustard seeds and

from animal fats).

% Biodiesel (other than agri-biodiesel)

This certificate applies to the following:

Invoice or delivery ticket number

Number of gallons

Producer understands that fraudulent use of this certificate may subject producer, claimant, and 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 Producer

Employer identification number

Address of Producer

Signature and date signed

Page 44

Publication 510 - Excise Taxes For 2005 - Department Of Treasury Page 44