03 Cert of Fuel Tax Exemption.doc

CERTIFICATE OF FUEL TAX EXEMPTION

EXEMPT SALES OF GASOLINE AND UNDYED DIESEL FUEL

Sections 78.01(2) & (2m), Wis. Stats.

Wisconsin Department of Revenue

Post Office Box 8900

Madison, WI 53708-8900

(608) 266-7363 or 266-6701

FAX (608) 261-7049

E-mail: excise@dor.state.wi.us

EFFECTIVE DATE: THIS EXEMPTION CERTIFICATE IS VALID FOR ONE YEAR FROM THE DATE IT IS SIGNED BY THE CUSTOMER AND SUPPLIER UNLESS CANCELED BY THE CUSTOMER, SUPPLIER OR THE DEPARTMENT.

Effective Date:

______________________ (enter date signed by customer and supplier)

Expiration Date:

______________________ (one year from effective date; time to execute another exemption certificate)

Wisconsin law allows a tax credit or refund to persons who sell tax-paid gasoline and undyed diesel fuel for exempt usage. Fuel suppliers who are licensed with the department may claim a deduction for exempt sales on the monthly motor vehicle fuel tax reports required to be filed with the department. Nonlicensed suppliers must file a refund claim (MF-012) with the department to receive a refund of the motor vehicle fuel tax they pay when purchasing the fuel for resale.

In order for a licensed supplier or a nonlicensed supplier to make exempt sales to customers, suppliers must obtain documentation like this exemption certificate from customers attesting to the exempt usage of the fuel purchased. If a customer makes exempt purchases from more than one supplier, the customer must execute an exemption certificate with each supplier. Suppliers and customers must retain copies of executed exemption certificates in their records. DO NOT SEND copies of exemption certificates to the department.

LAW CHANGE: Effective July 1, 1998, gasoline can once again be sold tax-exempt for off-road use (for example: farming, construction, logging). However, undyed diesel fuel must continue to be purchased tax-included but purchasers of this fuel can file an off-road refund claim with the department for a refund of the fuel tax relating to their off-road use. Call (608) 266-7363 or 266-6701 for refund claim forms.

AND Social Security No. (if you are

(FEIN)

a sole proprietor)

Signature of Customer

Title

Business Telephone

Date Signed

CUSTOMERS MUST INDICATE BELOW HOW THE EXEMPT FUEL WILL BE USED

( Customers must be prepared to substantiate usage if requested by representatives of the department.

CHECK ALL BOXES THAT APPLY.

FORMCHECKBOX

Gasoline purchased for off-road use in mobile machinery and equipment and delivered directly into the customer's storage tank in an amount not less than 100 gallons. Describe use:

Caution: Gasoline cannot be sold tax-exempt if it will be placed into the tank of a licensed motor vehicle (except an urban mass transportation vehicle), snowmobile, recreational motorboat, or an all-terrain vehicle unless registered for private use.

Gasoline bought for use in aircraft by a general aviation fuel dealer or user licensed with the Wisconsin Department of Revenue.

Gasoline purchased by an aviation fuel dealer or user must be delivered directly into the dealer or user's storage tank in an amount not less than 100 gallons.

Gasoline and/or undyed diesel fuel used by the U. S. Government or one of its agencies.

Indicate name of agency:

The U. S. Government is also exempt from the 3¢ per gallon petroleum inspection fee. (The State of Wisconsin, local municipalities in Wisconsin and school districts are not part of the U. S. Government, and cannot check this box.)

FORMCHECKBOX

Gasoline and/or undyed diesel fuel used by common motor carriers for the urban mass transportation of passengers.

FORMCHECKBOX

Undyed diesel fuel bought for use as heating oil.

FORMCHECKBOX

Gasoline and/or undyed diesel fuel exported by a person licensed to export with the Wisconsin Department of Revenue.

Other – describe use:

(For example: undyed diesel fuel sold for use in trains, fuel sold on a tribal reservation to Native Americans.)

PENALTIES: Any person who provides false or fictitious information on the exemption certificate or uses the fuel purchased tax-exempt in a manner not stated on the exemption certificate may be subject to tax, interest, penalties and fined not more than $500 or imprisoned not more than 6 months or both [section 78.73(1), Wis. Stats.].

MF-209 (R. 2-99)

THIS FORM MAY BE REPRODUCED