Model Certificate of Buyer of Taxable Fuel for Use by a State or Nonprofit Educational Organization (Notice_2005-80)

Model Certificate

OMB No. 1545-1915

CERTIFICATE OF BUYER OF TAXABLE FUEL FOR USE BY A STATE OR
NONPROFIT EDUCATIONAL ORGANIZATION
(To support credit card issuer’s claim for a credit, refund, or payment under § 6416(a)(4)(B) or § 6427(l)(6)(D) of the Internal
Revenue Code.)

Name, address, and employer identification number of credit card issuer.
The undersigned ultimate purchaser (“Buyer”) hereby certifies the following under the penalties of perjury (check one):
Buyer will use the taxable fuel to which this certificate relates for the exclusive use of a state; or
Buyer will use the gasoline to which this certificate relates for the exclusive use of a nonprofit educational
organization.
This certificate applies to all purchases made with the credit card identified below during the period specified:
1. Buyer’s account number
2. Effective date of certificate
3. Expiration date of certificate

.
.
(period not to exceed 2 years after the effective date).

Buyer will provide a new certificate to the credit card issuer 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 taxable fuel
purchased with the credit card to which this certificate relates.
Buyer acknowledges that it has not and will not claim any credit or payment for the taxable fuel purchased with the
credit card 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
(3) Current certificates held by credit
card issuers. A certificate also meets the
conditions of this paragraph (h) if it is similar to the certificate described in paragraph
(h)(2) of this section and was obtained by
the credit card issuer for purposes of processing a claim under § 6416 or 6427 as in
effect before January 1, 2006. These certificates expire on the earlier of January 1,
2007, or the expiration date on the certificate.

2005–46 I.R.B.

(i) Effective date. This section is effective January 1, 2006, and applies to claims
relating to fuel sold to its ultimate purchaser on or after that date.
Section 5. DIESEL-WATER FUEL
EMULSIONS
This section describes the changes
made by § 1343 of the Energy Act regarding diesel-water fuel emulsion. Effective

958

January 1, 2006, the rate of tax imposed
by § 4081 is reduced for diesel-water
fuel emulsion that meets the requirements
described in § 4081(a)(2)(D). These requirements include the registration under
§ 4101 of the person liable for tax on
the removal or sale of the diesel-water
fuel emulsion. Section 6427(m) provides
that a credit or payment is allowable if a
person uses diesel fuel taxed at the full
rate to produce diesel-water fuel emulsion

November 14, 2005