Form 637 UV 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.)

"UV" QUESTIONNAIRE

Activity Letter UV: Ultimate vendor that sells (a) undyed diesel fuel or undyed kerosene, to a state or local government for its exclusive use, or (b) gasoline (including aviation gasoline) to a state or local government for its exclusive use or to a nonprofit educational organization for its exclusive use.

See Notice 2005-4, Notice 2005-80, IRC 6416(a)(4)(A), IRC 6427(l)(5)(A)&(C)

The UV must be registered at the time of the sale in order to file a claim or refund of overpayment under IRC 6416.

1. Does your business qualify for the Form 637 “UV” 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 _“UV” 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 the business’s suppliers of gasoline, diesel fuel, and kerosene.

   Name and Address of Supplier	Gasoline	Diesel Fuel	Kerosene	Other
   	☐	☐	☐	☐
   	☐	☐	☐	☐
   	☐	☐	☐	☐
   	☐	☐	☐	☐
   	☐	☐	☐	☐
   	☐	☐	☐	☐
   	☐	☐	☐	☐

2. Does your business store any gasoline, kerosene, or diesel 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?

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   List all locations and storage facilities where gasoline, kerosene, and diesel fuel are stored that will sell undyed kerosene, undyed diesel fuel or gasoline to state/local governments or non- profit educational organizations. List the expected volume (gallons) of these sales.

Name and Address of Facility	Tank #	Product Stored	Expected Annual Volume (gallons)

Indicate with an (*) any facility where dyed diesel 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 get reimbursed for federal excise tax on fuels for any credit card sales?

☐ Yes ☐ No

If yes, please explain.

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

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   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 (*) for any customer who purchase in bulk quantities.

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   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 governments and/or nonprofit educational organizations?

10. 
    
    

    
    
    

    
    
    

    
    
    

    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? Who is filing claims for these sales to state/local government and nonprofit educational organizations?

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    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

12. Have any of your business’s 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?

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

Form 637 UV Questionnaire 4 Revised Feb 2022