Form 11a - K-1 Kerosene Exemption Certificate
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
11A
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
K-1 KEROSENE EXEMPTION CERTIFICATE
VENDOR INFORMATION
NAME OF VENDOR
FEIN OR SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
__ __ __ __ __ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
ADDRESS OF VENDOR
P.O. BOX
CITY
STATE
ZIP
___ ___ ___ ___ ___
OWNER’S OR OPERATOR’S NAME
I the undersigned, hereby certify that the dispensers at this location have been designed and constructed to prevent undyed K-1 kerosene from being
delivered directly from the dispenser into a vehicle supply tank. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as
defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.
OWNER’S OR OPERATOR’S SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
NAME OF SUPPLIER OR DISTRIBUTOR
LICENSE NUMBER
FEIN
__ __ __ __ __ __ __ __ __
SUPPLIER’S OR DISTRIBUTOR’S SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
MO 860-2096 (02-2011)
WHITE COPY — DISTRIBUTOR
YELLOW COPY — VENDOR
PINK COPY — SUPPLIER
This publication is available upon request in alternative accessible format(s)
MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
11A
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
K-1 KEROSENE EXEMPTION CERTIFICATE
VENDOR INFORMATION
NAME OF VENDOR
FEIN OR SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
__ __ __ __ __ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
ADDRESS OF VENDOR
P.O. BOX
CITY
STATE
ZIP
___ ___ ___ ___ ___
OWNER’S OR OPERATOR’S NAME
I the undersigned, hereby certify that the dispensers at this location have been designed and constructed to prevent undyed K-1 kerosene from being
delivered directly from the dispenser into a vehicle supply tank. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as
defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.
OWNER’S OR OPERATOR’S SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
NAME OF SUPPLIER OR DISTRIBUTOR
LICENSE NUMBER
FEIN
__ __ __ __ __ __ __ __ __
SUPPLIER’S OR DISTRIBUTOR’S SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
MO 860-2096 (02-2011)
WHITE COPY — DISTRIBUTOR
YELLOW COPY — VENDOR
PINK COPY — SUPPLIER
This publication is available upon request in alternative accessible format(s)
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