FORM 13-79
REVISED 11-2013
EXEMPTION CERTIFICATE
To support Buyer’s claim for an exemption from payment of Excise Tax levied under the Oklahoma Motor Fuel Tax Code.
(Vendor shall retain this document for not less than three (3) years)
______________________________________________ |
_______________________________________________ |
Name of Vendor |
Vendor FEIN |
_________________________________________________________________________________________________
Address of Vendor
_____________________________________________________ |
______________ |
__________________________ |
City |
State |
Zip Code |
To be submitted to the following Supplier, CNG and/or LNG Wholesaler/Retailer:
Name: ________________________________________ |
FEIN: __________________________________________ |
THIS EXEMPTION APPLIES TO: (CHECK ONLY ONE TYPE OF ENTITY)
COMPLETE A SEPARATE EXEMPTION CERTIFICATE FOR EACH EXEMPT ENTITY.
Public School District, FFA, 4-H Club for the Purpose of Transporting Public School Children
School District for Operation of Vehicles Used in Driver Training
Volunteer Fire Department |
Rural Electric Cooperative |
Rural Water and Sewer District |
Rural Amublance Service District |
Federally Recognized Indian Tribe |
Agency or Instrumentality of the United States |
City, County, or Town |
State of Oklahoma, Underground Storage Fee |
FOR PURCHASE OF: (CHECK WHICH FUEL TYPE(S) APPLY)
Gasoline |
Undyed Diesel |
(Number of Gallons: _____________________ ) |
(Number of Gallons: _____________________ ) |
CNG |
Petroleum Underground |
(Number of Gallons: _____________________ ) |
Storage (Number of Gallons: ______________ ) |
LNG
(Number of Gallons: _____________________ )
Period in which the fuel was purchased: _______________________________________________________________
The BUYER understands that the fraudulent use of this certiicate to obtain fuel without paying the tax levied will result in BUYER paying the tax, with penalties and interest.
______________________________________________ |
_______________________________________________ |
Name of Buyer |
Social Security Number or FEIN |
_____________________________________________________________________ ( ______ ) _________________
Address of BuyerTelephone Number of Buyer
_____________________________________________________ ______________ |
__________________________ |
City |
State |
Zip Code |
______________________________________________ |
_______________________________________________ |
Signature of Buyer |
Date Signed |
|
______________________________________________ |
_______________________________________________ |
Printed or Typed Name of Person Signing |
Title of Person Signing |
|
OMITTING Information required by Section 500.13 may result in the DISALLOWANCE of the Exemption.
Except for the ORIGINAL SIGNATURE, this form may be duplicated for future purchases.