Taxable Fuel Registrant Form

This category is about...

• Taxable fuel means gasoline, diesel fuel, and kerosene. Taxable fuel registrant means an enterer, industrial user, refiner, terminal operator, or throughputter that is registered as such under section 4101.

NOTIFICATION CERTIFICATE OF TAXABLE FUEL REGISTRANT
(Gasoline, Diesel or Kerosene)

Seller: ________________________________________
The undersigned taxable registrant (“Registrant”) hereby certifies under penalties of perjury that Registrant is
registered by the Internal Revenue Service with registration number (Form 637) and that
Registrant’s registration has not been revoked or suspended by the Internal Revenue Service.
Registrant understands that the fraudulent use of this certificate may subject Registrant and all parties making
such fraudulent use of this certificate to a fine or imprisonment, or both, together with the costs of prosecution.
This certificate is effective January 1, 2013 and is good until the earlier of (1) the date registrant provides a new
certificate or (2) the date the recipient of the certificate is notified by either the IRS or the registrant that the registrant’s
registration has been revoked or suspended.

___________________________________________
Signature and date signed

___________________________________________

Printed or typed name of person signing

___________________________________________
Name of Registrant
 

___________________________________________
Employer identification number