Form 637 D 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 D - Buyer with a place of business in the United States purchasing vaccines, gas guzzler automobiles, taxable tires, sport fishing equipment (including fishing rods and fishing poles), fishing tackle boxes, bows, quivers, broadheads, points, or arrow shafts for export or for resale to a second purchaser for export.

Registration allows a buyer to purchase article subject to excise tax tax-free from the manufacturer, only if the buyer intends to either export the article or resell it to a second buyer who intends to export it.

"D" QUESTIONNAIRE

1. Does your business qualify for the Form 637 “D” 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 _“D_” 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. List the name and address of suppliers and the applicable items purchased for export or for resale to a second purchaser for export.

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   List the name, address, and 637 registration number of all purchasers, or second purchaser to whom the company sells or intends to sell articles for export.

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   Please describe the proof of export your business plans to obtain to verify the articles were exported.

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   Provide the name and address of any brokers used to export products subject to excise tax.

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

Form 637 D Questionnaire 2 Revised Feb 2022