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FT-1014

New York State Department of Taxation and Finance

Certification for Non-Highway Diesel Motor Fuel and

Residual Petroleum Product Used for Commercial

(11/11)

Purposes (Other Than Manufacturing or Farming)

Purchasers and sellers: Read the information on page 2 and certifications below carefully before giving or accepting this certificate.

Sellers: Your sales are subject to the applicable taxes on diesel motor fuel or residual petroleum product unless the purchaser gives you a properly

completed certification no later than 90 days after the delivery of the product sold. Keep the certificate for at least three years.

Purchasers: This certificate must be completed by the purchaser and given to the seller.

Type or print

Name of seller

Name of purchaser

Address

(number and street)

City

State

ZIP code

City

State

ZIP code

Seller’s Certificate of Authority number

Purchaser’s Certificate of Authority number

Enter specific product type:

. (Use a separate Form FT-1014 for each product type.)

Single-purchase certificate — enter the invoice or delivery ticket number

and the number of gallons

Blanket certificate — will be considered part of any order given to you and will remain in force until revoked by written notice. It covers only

purchases of the specific product type indicated above.

Part 1 — Non-highway diesel motor fuel

Enter the percentage of fuel for each item below (must total 100%).

I certify that

% of the non-highway diesel motor fuel covered by this certificate is used for commercial purposes, other than

in the production for sale of tangible personal property, gas, electricity, refrigeration, or steam. The fuel will not be delivered to a filling

station or a tank equipped with a nozzle or other apparatus that can fuel a motor vehicle. (This sale is exempt from the diesel motor fuel

tax, but is subject to the petroleum business tax at the commercial gallonage rate for diesel motor fuel and, unless a different exemption

form is provided, New York State (NYS) and local sales taxes.)

I certify that

% of the fuel is to be used for nonresidential (commercial) heating purposes. (This sale is subject to the petroleum

business tax at the nonresidential heating rate for diesel motor fuel and NYS and local sales taxes, but exempt from the diesel motor fuel

tax.)

I certify that

% of the fuel is to be used for residential heating purposes. (This sale is exempt from the petroleum business tax,

the diesel motor fuel tax, and NYS sales tax, but, if applicable, subject to local sales tax.)

Part 2 — Residual petroleum product

Enter the percentage of product for each item below (must total 100%).

I certify that

% of the residual petroleum product covered by this certificate is used for commercial purposes, other than in the

production for sale of tangible personal property, gas, electricity, refrigeration, or steam. (This sale is subject to the petroleum business tax

at the commercial gallonage rate for residual petroleum product and, unless a different exemption form is provided, NYS and local sales

taxes.)

I certify that

% of the product is to be used for nonresidential (commercial) heating purposes. (This sale is subject to the

petroleum business tax at the nonresidential heating rate for residual petroleum product and to NYS and local sales taxes.)

I certify that

% of the product is to be used for residential heating purposes. (This sale is exempt from the petroleum business

tax and NYS sales tax, but, if applicable, subject to local sales tax.)

Note: Kerosene is exempt from the petroleum business tax when sold by a petroleum business registered as a distributor of diesel motor fuel or a retailer

of non-highway diesel motor fuel only and the kerosene is not mixed or blended with other products, is not sold with any other petroleum product, or

is not sold or used to operate motor vehicles or delivered into a tank equipped with a nozzle.

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.

Signature of purchaser or authorized representative

Title

Date