Form 637 UB 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 UB - Ultimate vendor that sells undyed diesel fuel or undyed kerosene for use in certain intercity and local buses.

See Notice 2005-04, section 5(g)(1).

Registration allows a registered ultimate vendor that sells undyed diesel fuel or undyed kerosene to the ultimate purchaser for use in certain intercity and local buses to file a claim for credit or refund if the ultimate purchaser waives its right to the credit or refund.

"UB" QUESTIONNAIRE

1. Does your business qualify for the Form 637 “UB” 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 _“UB” 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. Does your business have an exclusive contract to sell undyed diesel fuel or undyed kerosene for certain intercity and local buses?

☐ Yes ☐ No

If yes, please explain.

3. 
   
   

   
   
   

   
   
   

   
   
   

   Is your business registered or required to be registered by state or local authorities for the petroleum business?

☐ Yes ☐ No

If yes, list the licensing agencies and numbers and dates granted.

4. 
   
   

   
   
   

   
   
   

   
   
   

   List all locations and storage facilities where diesel fuel is stored. List the expected volume (in gallons) of diesel fuel sold at each facility. If facility does not have bulk storage, and all diesel fuel is delivered directly into the fuel supply of buses, notate “Bus” in the column "Capacity of Tanks.”

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

Indicate with an (*) any tank that contains dyed diesel or dyed kerosene

5. Does your business file claims for undyed diesel fuel or undyed kerosene used in intercity or local buses?

☐ Yes ☐ No

If yes, what form is your business using to file the claim?

6. 
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   Does your business sell diesel fuel or kerosene for public or private school buses?

☐ Yes ☐ No

If yes, provide the name and address of the bus company or school district.

7. 
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   Does your business sell diesel fuel or kerosene for use in a regular scheduled intercity or local bus transportation?

☐ Yes ☐ No

If yes, provide the route schedules.

8. 
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   
   
   

   Does your business store any diesel fuel or 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?

9. 
   
   

   
   
   

   
   
   

   
   
   

   List all locations and storage facilities where diesel fuel or kerosene is stored that will sell undyed diesel fuel or kerosene to intercity and local buses. List the expected volume (in gallons) of undyed diesel fuel or kerosene sold to these entities.

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

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

10. 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

11. Is your business or your business’s customers reimbursed for the federal excise tax on diesel fuel or kerosene for any credit card sales?

☐ Yes ☐ No

If yes, provide details.

12. 
    
    

    
    
    

    
    
    

    
    
    

    What is your business’s procedures for securing exemption certificates from customers who purchase without the federal excise tax?

13. 
    
    

    
    
    

    
    
    

    
    
    

    List the names and addresses of all customers that your business has sold or plans to sell undyed diesel fuel and/or kerosene without the federal excise tax? Indicate with an (*) any customer who purchases in bulk quantities.

14. 
    
    

    
    
    

    
    
    

    
    
    

    
    
    

    Does your business store any fuel 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? Who is filing claims for these sales to state/local government?

15. 
    
    

    
    
    

    
    
    

    
    
    

    Does your business sell undyed diesel fuel and/or kerosene on consignment?

☐ Yes ☐ No

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

16. 
    
    

    
    
    

    
    
    

    
    
    

    Have any of your business drivers inadvertently mixed undyed diesel fuel with dyed diesel fuel (or vice versa) or kerosene?

☐ Yes ☐ No

If yes, what was done with the fuel and was a claim filed?

17. 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

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

Form 637 UB Questionnaire 3 Revised Feb 2022