Model Certificate for State Use or Nonprofit Educational Organization Use (Notice 2005-4)

OMB No. 1545-1915
Model Certificate

sult in multiple refund claims with respect
to the same transaction. Congress may
wish to address this issue prior to March
1, 2005, and Treasury and the Service will
assist Congress in designing an administrable alternative.
(2) Claims by the ultimate purchaser. A
claim for a credit or refund under § 6416
by the person that paid the tax (or that is
treated as having paid the tax) is an alternative to a claim for an income tax credit
or payment under § 6421(c) by the ultimate
purchaser (that is, the state or nonprofit educational organization). For any particular
transaction, a claim may not be made under
§ 6421(c) if the tax is credited or refunded
under § 6416 to either the ultimate vendor
or the person that actually paid the tax.
(b) Definitions.
Nonprofit educational organization
has the meaning given to the term in
§ 4221(d)(5).
Registered ultimate vendor is a person
that sells gasoline to a state for its exclusive use or to a nonprofit educational organization for its exclusive use and is registered as an ultimate vendor under § 4101.
State has the meaning given to the term
by § 48.4081–1(b).
(c) Conditions to allowance of a credit
or refund. A claim for credit or refund of
an overpayment of tax is allowable under
§ 6416(b)(2)(C) or (D) and § 6416(a)(4)
(relating to refunds of gasoline tax to registered ultimate vendors) if—

(1) The claimant sold the gasoline to a
state for its exclusive use or to a nonprofit
educational organization for its exclusive
use;
(2) The claimant is a registered ultimate
vendor; and
(3) The claim contains all of the information required in paragraph (e).
(d) Form of claim—(1) In general. A
claim under § 6416(b)(2)(C) or (D) and
§ 6416(a)(4) is made—
(i) In the case of a claim for a refund,
on Form 8849, Claim for Refund of Excise
Taxes; and
(ii) In the case of a claimant reporting
liability on Form 720, as a claim on Form
720 for an excise tax credit.
(2) Electronic claim certification to the
Secretary. Section 6416(a)(4)(B) provides
that electronic claims for refund under
§ 6416(a)(4) will be paid with interest if
the claim is not paid within 20 days of the
date it is filed and the claimant certifies
that all ultimate purchasers are certified
and entitled to a refund. This notice does
not provide guidance on these certification procedures. These procedures and the
procedures for filing an electronic claim
will be prescribed in subsequent guidance.
(e) Content of claim. Each claim under § 6416(b)(2)(C) or (D) or § 6416(a)(4)
for a credit or payment must contain the
following information with respect to the
gasoline covered by the claim:
(1) The total number of gallons.

(2) The claimant’s registration number.
(3) A statement that the claimant—
(i) Has not included the amount of the
tax in its sales price of the gasoline and
has not collected the amount of tax from
its buyer;
(ii) Has repaid the amount of the tax to
the ultimate purchaser of the fuel; or
(iii) Has obtained the written consent of
its buyer to allowance of the claim.
(4) A statement that the claimant has in
its possession an unexpired certificate described in paragraph (f) of this section and
has no reason to believe any information in
the certificate is false.
(f) Certificate—(1) In general. The certificate to be provided to the ultimate vendor consists of a statement that is signed
under penalties of perjury by a person with
authority to bind the buyer, is in substantially the same form as the model certificate in paragraph (f)(2) of this section, and
contains all of the information necessary to
complete such model certificate. A new
certificate must be given if any information in the current certificate changes. The
certificate may be included as part of any
business records normally used to document a sale. The certificate expires on the
earlier of the following dates:
(i) The date one year after the effective
date of the certificate.
(ii) The date a new certificate is provided.
(2) Model certificate.

CERTIFICATE FOR STATE USE OR NONPROFIT EDUCATIONAL
ORGANIZATION USE
(To support ultimate vendor’s claim for a credit or refund under § 6416(a)(4) of the Internal Revenue Code.)

Name, address, and employer identification number of ultimate vendor
The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under the penalties of perjury:
Buyer will use the gasoline to which this certificate relates (check one):
For the exclusive use of a state; or
For the exclusive use of a nonprofit educational organization.
This certificate applies to the following (complete as applicable):

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300

January 10, 2005

This is a single purchase certificate:
1.

Invoice or delivery ticket number

2.

Number of gallons

This is a certificate covering all purchases under a specified account or order number:
1. Effective date
2. Expiration date

(period not to exceed 1 year after the effective date)

3. Buyer account number
Buyer will provide a new certificate to the vendor if any information in this certificate changes.
Buyer understands that by signing this certificate, Buyer gives up its right to claim a credit or payment for the gasoline to
which this certificate relates.
Buyer acknowledges that it has not and will not claim any credit or payment for the gasoline to which this certificate relates.
Buyer understands that the fraudulent use of this certificate may subject Buyer and all parties making such fraudulent use of
this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
Printed or typed name of person signing
Title of person signing
Name of Buyer
Employer identification number
Address of Buyer
Signature and date signed
(g) Registration—(1) In general. Application for registration as a registered ultimate vendor of gasoline is made on Form
637, Application for Registration (For Certain Excise Tax Activities), in accordance
with the instructions for that form. A person that is registered under § 4101 under
Activity Letter “UV” or “UP” (Ultimate
vendor that sells kerosene from a blocked
pump) is treated as registered for purposes
of claims under this section and will not
have to be reregistered unless notified to
do so by the Service.
(2) Requirements. The Service will register an applicant as an ultimate vendor of
gasoline only if the Service—
(i) Determines that the applicant is, in
the course of its trade or business, regularly
engaged as a seller of gasoline to states or
nonprofit educational organizations, or is
likely to become so engaged within a reasonable time after being registered under
§ 4101; and

January 10, 2005

(ii) Is satisfied with the filing, deposit, payment, reporting, and claim history for all federal taxes of the applicant
and any related person (as defined in
§ 48.4101–1(b)(5)).
Section 8. TWO-PARTY EXCHANGES
Section 4105(a) provides that in a twoparty exchange, as defined in § 4105(b),
the delivering person is not liable for the
tax imposed on the removal of taxable fuel
from the terminal at the terminal rack. Under this notice, in a two-party exchange
the receiving person is liable for the tax
imposed on the removal of taxable fuel
from the terminal at the terminal rack. For
purposes of § 48.4081–2(c)(2) (relating to
the joint and several liability of a terminal operator), the “position holder” will include the receiving person in a two-party
exchange. Also, a delivering person may
treat a receiving person as a taxable fuel
registrant for purposes of § 4105(b) if, at

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the time of the exchange, the delivering
person has an unexpired notification certificate (described in § 48.4081–5) from
the receiving person and has no reason to
believe any information in the certificate is
false.
Section 9. GASOLINE BLENDS,
TRANSMIX, DIESEL FUEL
BLENDSTOCKS
(a) Gasoline blends. Section 4083(a)
(2) defines gasoline as including
gasoline blends other than qualified
methanol or ethanol fuel (as defined
in § 4041(b)(2)(B)), partially exempt
methanol or ethanol fuel (as defined in
§ 4041(m)(2)) or a denatured alcohol.
Thus, for example, gasoline includes any
gasoline/ethanol blend unless at least 85
percent of the blend consists of alcohol
made from coal, at least 85 percent of the
blend consists of alcohol made from nat-

2005–2 I.R.B.