Appendix B--Model Certificate B. Summary: This is an example of a certificate which reports information about the seller of taxable fuel within the bulk transfer/terminal
system if he receives a copy of the first taxpayer's report. It contains the following text:STATEMENT OF SUBSEQUENT SELLER.
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“1. Name, address, and employer identification number of seller in subsequent sale” field
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“2. Name, address, and employer identification number of the buyer in subsequent sale” field
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“3. Date and location of subsequent sale” field
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“4. Volume and type of taxable fuel sold” field
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The undersigned seller (
“Seller”) has received the copy of the first taxpayer's report provided with this statement in connection with Seller's purchase
of the
taxable fuel described in this statement.Under penalties of perjury, Seller declares that Seller has examined this statement,
including any accompanying schedules and statements, and,
to the best of Seller's knowledge and belief, they are true, correct and complete.
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“Signature and date signed” field
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“Printed or typed name of person signing this report” field
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“Title” field
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