Form Ft-939 - Certificate Of Tax Exemption For A Qualified Indian Nation Or Tribe On Purchases Of Motor Fuel, Diesel Motor Fuel, And Cigarettes
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1
2New York State Department of Taxation and Finance
FT-939
Certificate of Tax Exemption for a Qualified
(7/03)
Indian Nation or Tribe on Purchases of Motor
Fuel, Diesel Motor Fuel, and Cigarettes
To be completed by the nation or tribe and given to the seller, who must keep it for at least three years as explained in the instructions on
the back page of this form.
This certificate may be used only by a qualified Indian nation or tribe purchasing products for official nation or tribal government use or
consumption and is not valid for purchases for resale or for purchases made and delivered off a qualified reservation. It is acceptable
as proof of exemption from state taxes on purchases of any or all of the products checked below, provided that all required criteria are met,
all required entries are completed, and a photocopy of the nation’s or tribe’s Form ST-119, Exempt Organization Certificate , is attached. The
copy of Form ST-119 must remain with this certificate.
Check applicable boxes:
Motor fuel
Diesel motor fuel (including heating oil)
Cigarettes
Part I — To be completed by nation or tribe (authorized representative)
Name of nation or tribe
(please print or type)
Street address
City
State
ZIP code
I, the undersigned, hereby certify that the nation or tribe named above is buying the products for official use and not for resale, and that the
nation or tribe holds a valid Form ST-119, number EX -
, a copy of which is attached.
Signature of authorized representative of nation or tribe
Title
Date
Part II — To be completed by vendor
Name of vendor
(please print or type)
Street address
City
State
ZIP code
I, the vendor, hereby certify that the motor fuel, diesel motor fuel, or cigarettes were sold in compliance with the terms of this certificate to the
above-named Indian nation or tribe and were delivered directly to that nation or tribe on a qualified reservation.
Signature of vendor
Date
By accepting this certificate, you are authorized to sell to the above-named Indian nation or tribe motor fuel, diesel motor fuel, or cigarettes
free of state taxes. This certificate, when properly completed, is your evidence that the purchaser is exempt from payment of the state taxes
otherwise due on a retail sale.
Failure to comply with the requirements outlined in this certificate may subject you to liability for tax and the imposition of civil and criminal
sanctions including penalty assessment, loss of product, and the suspension or revocation of any license or registration.
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