Form Ft-1002 - Certification Of Use Of Diesel Motor Fuel Purchased In Volume printable pdf download

FT-1002

New York State Department of Taxation and Finance

Certification of Use of Diesel Motor Fuel

(6/12)

Purchased in Volume

This certificate is to be used by retail filling stations to purchase diesel product for resale and by

diesel motor fuel distributors to purchase highway diesel motor fuel for resale. It may not be used by

distributors of kero-jet fuel only or retailers of non-highway diesel motor fuel only.

This certificate must be completed by the purchaser and given to the seller, who must keep it for at least three years after the date of the last

sale substantiated by this certificate.

Read all statements and certifications carefully before issuing or accepting this certificate.

Name of seller

Name of purchaser

Street address

City

State

ZIP code

City

State

ZIP code

Purchaser’s NYS diesel motor fuel registration number (if any)

Mark an X in the applicable box:

Purchaser’s NYS Certificate of Authority number

Single-purchase certificate

Blanket certificate

Unless this is marked above as a Single-purchase certificate, it shall be considered part of any order given to you and shall remain in force

until revoked by written notice to you.

Invoice number or

Specific product

delivery ticket number

(for example, No. 2 fuel oil)

Gallons purchased

Diesel motor fuel means No. 1 diesel fuel, No. 2 diesel fuel, biodiesel, kerosene, fuel oil or other middle distillate and also motor fuel suitable

for use in the operation of an engine of the diesel type. It does not include any product specifically designated No. 4 diesel fuel.

Non-highway diesel motor fuel means any diesel motor fuel that is designated for use other than on a public highway (except for the use of

the public highway by farmers to reach adjacent lands), and is dyed diesel motor fuel.

Highway diesel motor fuel means any diesel motor fuel which is not non-highway diesel motor fuel.

Dyed diesel motor fuel means diesel motor fuel which has been dyed in accordance with and for the purpose of complying with the

provisions of 26 USC 4082(a).

Mark one:

I certify that the diesel motor fuel being purchased by me is for resale through my retail filling station. I will collect the applicable taxes

on my sale.

I certify that I am a distributor of diesel motor fuel and the product being purchased by me is highway diesel fuel that I will resell. I will

collect the applicable taxes on my sale.

Signature of purchaser or authorized representative

Title

Date

To the purchaser: Furnishing false or fraudulent information in completing this certificate with the intention of avoiding payment of a proper

amount of tax shall make you jointly and severally liable for the tax and may also subject you to substantial civil and criminal penalties.

To the seller: Do not accept this certificate if it is incomplete. Upon receipt of this certificate, properly completed, you are authorized to

pass through the prepaid sales tax in lieu of the state and local sales tax. On each sale, you must give the purchaser proper certification of

the taxes paid.

Form Ft-1002 - Certification Of Use Of Diesel Motor Fuel Purchased In Volume

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