Form Mfd-3 - Motor Fuel Excise Tax & Prepaid State Tax Exemption Certificate

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MFD-3
(Rev. 2/05)
Department of Revenue
MOTOR FUEL EXCISE TAX & PREPAID STATE TAX EXEMPTION CERTIFICATE
To:
_______________________________
From:
_____________________________
Licensed Distributor (please print)
Purchaser (please print)
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
(Distributor’s address)
(Purchaser’s address)
_____________________________
_____________________________
(Distributor’s telephone number)
(Purchaser’s telephone number)
The above named purchaser is buying jet fuel or special fuel from the above named Licensed
Distributor exempt from Georgia motor fuel excise tax under O.C.G.A. § 48-9-3(b) (7) (B) (ii) (l) because
the purchaser has no highway use of such fuels nor is the purchaser a reseller of such fuels. The
purchaser acknowledges that the terms “jet fuel”, “special fuel”, and “highway use”, as used within this
exemption certificate, have the same definitions as found under the Georgia Motor Fuel Tax Law and
related rules and regulations promulgated by the state revenue commissioner.
This exemption certificate shall be valid for a period no longer than three years from the date
listed below. The purchaser must immediately notify the above Licensed Distributor if it no longer
qualifies for the exemption during this three year period. Any purchaser who falsely claims this exemption
or fails to rescind the exemption certificate to the distributor in writing when the purchaser is no longer
eligible for the exemption, shall be deemed a distributor for purposes of taxation and is subject to all of
the provisions of the Georgia Motor Fuel Tax Law and related rules and regulations.
All licensed distributors who receive this exemption certificate must provide a copy to the
Georgia Department of Revenue no later than thirty days after receipt from a purchaser.
_____________________
__________________________________________
Date
Name of Purchaser (please print)
__________________________________________
RETURN TO:
Name and title of corporate officer or other responsible party
Georgia Dept. of Revenue
___________________________________
Motor Fuel Tax Unit
Signature
1800 Century Blvd., NE, Suite 8223
Atlanta, GA 30345-3205

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