Form 637 BC Questionnaire OMB_Rev_Feb_2022

Name:		EIN:
Address:		637 Reg No.:
City, State, Zip:		OMB No.:	1545-1835

In addition to the Form 637 General Questionnaire, please answer the following questions specific to this activity. (Attach additional sheets, if needed.)

Activity Letter BC: Qualified blood collector organization buying taxable fuel, taxable tires, and certain heavy vehicles; claiming exemption from the communications tax and heavy highway vehicle use tax; or to claim a credit or payment of certain excise taxes, for its exclusive use in the collection, storage, or transportation of blood. See Notice 2006-92, section 7.

“BC” QUESTIONNAIRE

1. Does your business qualify for the Form 637 “BC” Registration?

☐ Yes ☐ No

• If yes, please complete questions below and return this form.

• If no, please sign the statement below, date, and return this form.

I request my Form 637 _“BC” Registration be denied or revoked as I am no longer engaged in this activity.

____________________________________ __________________

Printed Name Title

____________________________________ __________________

Signature Date

Note: This request must be signed by a person with authority to bind the applicant or registrant. Refer to Form 637, Application for Registration (For Certain Excise Tax Activities), General Instructions, under the Signature section for additional guidance.

1. Is your business primarily engaged in the activity of collecting human blood?

☐ Yes ☐ No

3. Does your business have an IRS Determination Letter under 501(c)?

☐ Yes ☐ No

If yes, please provide a copy.

4. Does your business have evidence of registration from the Food and Drug Administration as a Blood Collector for each facility that your business owns and/or operates?

☐ Yes ☐ No

If yes, please provide a copy.

5. Furnish the following information for all vehicles used in the transportation of human blood.

   Model	Year	License Plate #	Type of Fuel (Gas/Diesel)	Tire Size

6. What is the estimated number of tires purchased annually for all vehicles used in the transportation of human blood?

7. 
   
   

   
   
   

   
   
   

   
   
   

   List the name and address of all your business’s tire suppliers.

   Name	Address

8. List the name and phone number of a person whom we can contact about this application/registration.

Form 637 BC Questionnaire 3 Revised Feb 2022