Form 91ex - Nebraska Tax Exempt Certificate For Purchase Of Undyed Diesel Fuel
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Nebraska Tax Exempt Certificate for Purchase of Undyed Diesel Fuel
Exclusively for Temperature Control Units (Reefers) and Power-Take-0ff Units
91EX
NAME AND MAILING ADDRESS OF CONSUMER
NAME AND MAILING ADDRESS OF SELLER
Name
Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Federal Employer ID or Social Security Number
Federal Employer ID or Social Security Number
Check Type of Certificate
Single
Blanket
If Blanket is checked, this certificate expires one year from the date issued.
I certify that the undyed diesel fuel and undyed biodiesel blends purchased tax free with this certificate will only be placed into a separate
supply tank for temperature control units (reefers) or power-take-off units. This exemption is further limited to purchases of 50 gallons
or less, and the supply tank cannot be connected to the engine or main fuel supply tank of a licensed motor vehicle.
Any consumer or agent who completes this certificate for purchases which are not exempt under the Nebraska Motor Fuels
Tax Statutes, as amended, is subject to the applicable tax, interest, and also a penalty of $1,000 for each violation.
I understand that by completing this certificate I am subject to audit, and that under penalties of law, I declare that I have examined this certificate and
to the best of my knowledge and belief, it is correct and complete.
sign
(
)
here
Authorized Signature of Consumer
Date Issued
Phone Number
Sellers must keep this certificate as part of their records.
9-2013
3-452-1995 Rev.
Supersedes 3-452-1995 Rev. 11-2010
Instructions
Who Must File. Any purchaser meeting the statutory requirements to purchase undyed diesel fuel tax free must
issue a Nebraska Tax Exempt Certificate for Purchase of Undyed Diesel Fuel, Form 91EX, to support all tax-free
purchases. The Form 91EX is issued to the seller.
For purposes of this certificate, diesel fuel includes unblended diesel, diesel fuel containing blending agents such as
kerosene, and biodiesel blends such as B-2 and B-10.
Undyed diesel fuel can be purchased tax free only when used in temperature control units (reefers) or power-take-off
units. Purchases are limited to 50 gallons or less and must be placed into a separate supply tank not connected to the
engine or main fuel supply tank of a licensed motor vehicle.
The federal government can purchase undyed diesel fuel tax free and is not required to issue a Form 91EX.
Tax-paid Undyed Diesel Fuel. All undyed diesel fuel must be purchased tax paid except when the purchaser is
qualified to issue a Form 91EX as described above.
The consumer may file for a refund of tax paid on undyed diesel fuel when the fuel is used in unlicensed equipment.
Nebraska Non-Ag Use Motor Fuels Tax Refund Claim, Form
84, or
The claim for refund must be made on the
Nebraska Ag Use Motor Fuels Tax Refund Claim, Form
84AG.
Type of Certificate. A single certificate applies to only one transaction. A blanket certificate applies to all qualified
transactions occurring for one year from the date issued.
Records. Consumers completing a Form 91EX must retain records documenting all usage of undyed diesel fuel
for a period of at least three years.
Sellers of tax-free undyed diesel fuel must retain this certificate, copies of invoices documenting each sale for
50 gallons or less, and all other records substantiating this certificate for at least three years.
For additional information, please contact the Motor Fuels Division, PO Box 98904, Lincoln, NE 68509-8904, or
call 800-554-FUEL (800-554-3835), 402-471-5730, or website at revenue.ne.gov/fuels.
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