Form 637 UA 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 UA: Ultimate vendor that sells kerosene for use in aviation.

See Notice 2005-04, section 4(h)(7).

Registration allows the registered ultimate vendor to make a claim for credit or payment for kerosene that was sold to the ultimate purchaser for nonexempt use in noncommercial aviation or kerosene used in commercial aviation (other than foreign trade).

Note: In order to make a claim for credit or payment for sales of kerosene for use in aviation by a State or Local Government, a UV registration is required.

“UA” QUESTIONNAIRE

1. Does your business qualify for the Form 637 “UA” 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 _“UA” 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 all your business’s suppliers of kerosene.

2. 
   
   

   
   
   

   
   
   

   Does your business store any kerosene to which it does not hold title?

☐ Yes ☐ No

If yes, where is this inventory stored? For whom is it stored? Are separate inventory records maintained?

4. 
   
   

   
   
   

   
   
   

   List all locations and storage facilities where kerosene is stored. List the expected volume (in gallons) of kerosene sold.

Name and Address of Facility	Capacity of Kerosene Fuel Tank(s)	Expected Annual Volume (gallons)

Indicate with an (*) any facility where dyed kerosene fuel is sold.

5. Are all pumps dispensing dyed diesel fuel or kerosene labeled with the correct legible and conspicuous notice?

Dyed Diesel Fuel - DYED DIESEL FUEL, NONTAXABLE USE ONLY, PENALTY FOR TAXABLE USE ☐ Yes ☐ No ☐NA

Dyed Kerosene - DYED KEROSENE, NONTAXABLE USE ONLY, PENALTY FOR TAXABLE USE ☐ Yes ☐ No ☐NA

6. Does your business own fuel transports? ☐ Yes ☐ No

If yes, list Vehicle Identification Number (VIN), Gross Vehicle Weight (GVW), fuel transported and capacity of each.

VIN	GVW	Fuel Transported	Capacity

7. Is your business or your customers reimbursed for the federal excise tax on kerosene for any credit card sales?

☐Yes ☐ No

If yes, please explain.

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   What is your business’s procedures for securing exemption certificates from customers who purchase at a reduced federal excise tax rate and/or without the federal excise tax?

9. 
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   Describe any fueling agreements with other carriers.

10. 
    
    

    
    
    

    
    
    

    
    
    

    Does your business claim credit or refunds for excise taxes on sales of aviation fuel?

☐ Yes ☐ No

If yes, please explain.

11. 
    
    

    
    
    

    
    
    

    
    
    

    
    
    

    Please list all customers that your business sells aviation kerosene to at a tax free or reduced tax rate. If your business has secured an exemption certificate from these customers, please provide a copy.

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

Form 637 UA Questionnaire 2 Revised Feb 2022