Form 637 E 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 E - Buyer (other than state or local government) of gas guzzler automobiles for ambulance, law enforcement, or firefighting. See 4064(b)(1)(C).

Allows a buyer to purchase gas guzzler automobiles (emergency vehicles) tax-free from the manufacturer. The buyer must use the vehicles for ambulances, law enforcement, or firefighting services.

“E” QUESTIONNAIRE

1. Does your business qualify for the Form 637 “E” 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 _“E_” 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 make, model, Gross Vehicle Weight (GVW), and fuel economy rating of the gas-guzzler automobiles that your business will be buying for use and used as an ambulance, in law enforcement, or in firefighting.

   Make	Model	GVW	Fuel Economy Rating

2. List the name, and address of your business’s suppliers of gas-guzzler automobiles purchased for use and used as an ambulance, in law enforcement, or in firefighting.

3. 
   
   

   
   
   

   
   
   

   
   
   

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

Form 637 E Questionnaire 2 Revised Feb 2022