Publication 225: Farmer's Tax Guide;

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Table 14-3. Sample Exemption Certificate. Summary: This is an example of an exemption certificate to be presented to a vendor when purchasing undyed diesel fuel or kerosene for farming purposes in order to exempt buyer from excise tax. It contains the text:EXEMPTION CERTIFICATE. (To support vendor's claim for credit or payment under section 6427 of the Internal Revenue Code) “Name, Address, and Employer Identification Number of Seller” fieldThe undersigned buyer ( “Buyer”) hereby certifies the following under penalties of perjury:

A. Buyer will use the diesel fuel or kerosene to which this certificate relates either--(check one):

(checkbox) “1. On a farm for farming purposes (as defined in section 48.6420-4 of the Manufacturers and Retailers Excise Tax Regulations) and Buyer is the owner, tenant, or operator of the farm on which the fuel will be used; or”

(checkbox) “2. On a farm (as defined in section 48.6420-4 (c)) for any of the purposes described in paragraph (d) of that section (relating to cultivating, raising, or harvesting) and Buyer is not the owner, tenant, or operator of the farm on which the fuel will be used.”

B. This certificate applies to the following (complete as applicable):
1. “1. If this is a single purchase certificate, check here (checkbox) and enter:”
2. 1. “a. Invoice or delivery ticket number” field
  2. “b. Number of gallons” field
3. “2. If this is a certificate covering all purchases under a specified account or order number, check here (checkbox) and enter”
4. 1. “a. Effective date” field
  2. “b. Expiration date (period not to exceed 1 year after effective date)” field
  3. “c. Buyer account or order number” field

Buyer will provide a new certificate to the seller if any information in this certificate changes.
If Buyer uses the diesel fuel or kerosene to which this certificate relates for a purpose other than stated in the certificate, Buyer will be liable for any tax.
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.

“Signature and Date Signed” field

“Printed or Typed Name and Title of Person Signing” field

“Name, Address, and Employer Identification Number of Buyer” field