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FT-1004

New York State Department of Taxation and Finance

Certificate for Purchases of Non-Highway Diesel Motor Fuel or

(6/12)

Residual Petroleum Product for Farmers and Commercial Horse

Boarding Operations

To purchasers and sellers: Carefully read the information on page 2 of this form and the certifications below before giving or accepting this

certificate.

To sellers: You must collect the applicable taxes on the sale of diesel motor fuel or residual petroleum product unless the purchaser gives

you a properly completed exemption document no later than 90 days after the delivery of the product sold. Keep the certificate for at least

three years from the last sale covered by this certificate.

To purchasers: Complete this certificate and give it to the seller.

Please type or print

Name of seller

Name of farmer or commercial horse boarding operator

Street address

City

State

ZIP code

City

State

ZIP code

Single-purchase certificate — enter invoice number

and number of gallons

Blanket certificate — will be considered part of any order given and will remain in effect until revoked by written notice

from the purchaser or until the Tax Department notifies you that the purchaser may not make exempt purchases. It covers only

the types of purchases marked below. If the conditions change for any of the boxes marked below (a, b, c, or d), complete a new

Form FT-1004 to cover the new types of purchases.

Part 1 — For non-highway diesel motor fuel purchases only

(mark an X in box a or b)

% of the non-highway diesel motor fuel will be consumed directly and exclusively in the production of

I certify that

tangible personal property for sale by farming, and all of the non-highway diesel motor fuel covered by this certificate will be

delivered to my farm site, and will not be consumed on the public highways of this state except to reach adjacent farmlands

(exempt from diesel motor fuel tax, petroleum business tax, and sales tax).

I certify that

% of the non-highway diesel motor fuel will be used or consumed either in the production of tangible personal

property for sale by farming or in a commercial horse boarding operation (see definition on back), or in both, and will not be

consumed on the public highways of this state except to reach adjacent farmlands or adjacent lands used in a commercial horse

boarding operation, or both (subject to petroleum business tax at the commercial gallonage rate, but exempt from diesel motor fuel

tax and sales tax).

Part 2 — For residual petroleum product purchases only

(mark an X in box c or d)

I certify that

% of the residual petroleum product will be used or consumed directly and exclusively in the production of

tangible personal property for sale by farming, and all of the residual petroleum product covered by this certificate will be delivered

to my farm site (exempt from petroleum business tax and sales tax).

I certify that

% of the residual petroleum product will be used or consumed in the production of tangible personal property

for sale by farming or in a commercial horse boarding operation (see definition on back), or both (exempt from sales tax, but

subject to petroleum business tax at the commercial gallonage rate).

Certification: I certify that the above statements are true and complete, and I make these statements with the knowledge that willfully

issuing a false or fraudulent certificate with the intent to evade tax is a misdemeanor under New York State Tax Law sections 1812(c)(4),

1812-f(c)(4), and 1817(m) and Penal Law section 210.45, punishable by a fine up to $10,000 for an individual or $20,000 for a corporation.

I also understand that the Tax Department is authorized to investigate the validity of exemptions claimed or the accuracy of any

information entered on this form.

Type or print name of farmer, commercial horse boarding operator, or representative

Signature of farmer, commercial horse boarding operator, or representative

Date

Form Ft-1004 - Certificate For Purchases Of Non-Highway Diesel Motor Fuel Or Residual Petroleum Product For Farmers And Commercial Horse Boarding Operations

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