Form FT-1003: October 1997, Statement of Exportation of Diesel Motor ...

Part of content:

Form FT-1003: October 1997, Statement of Exportation of Diesel Motor Fuel by Purchase, FT1003












To be completed bythe purchaser andgiven to the seller, whomust keep it for atleast three years afterthe date of the salesubstantiated by thiscerticate.
New York State Department of Taxation and Finance
Statement of Exportation of Diesel Motor Fuel
by Purchaser
This certicate must be issued before or at the time of purchase.
It will be acceptable as proof of export only if all entries are completed and thephotocopy or letter referred to below is attached. This form may only be accepted bya Distributor of Diesel Motor Fuel. It cannot be accepted by a Retailer of Heating OilOnly or Distributor of Kero-Jet Fuel Only.
This is asingle-purchasecerticate. Aseparate certicatemust be issued foreach purchase.
Name of seller
(must be a Distributor of Diesel Motor Fuel)
Street address
City
State
ZIP code
Date of delivery
Name of purchaser
Street address
City
State
ZIP code
Federal employer identication number
(if any)
NYS sales tax ID number
(if any)
NYS diesel registration number
(if any)
I certify that:
1.
I am purchasing the following diesel product from the above-named seller, and the diesel motor fuel tax, petroleum business tax andprepaid sales tax are not being passed through to me:
Invoice Number or
Delivery Ticket Number
Specic Product
Gallons Purchased
2.
I will not subsequently resell, deliver or use this diesel product in New York State.
3.
This diesel product will be immediately transported from New York State to the state or province ofwhere it will be either (check applicable box and furnish address if requested):
sold or used at my facilities located at
or
street, city, state or province
delivered to my customers facility at
or
street, city, state or province
delivered directly to consumers for their use outside New York State.
4.
The fuel is being transported by
and the mode of
name of transporter
transportation is by
truck, pipeline, railroad, etc.
5.
Based on the laws of the state or province named in item 3 above, it is lawful for me to import diesel motor fuel there and (checkone):
I certify that I am a duly licensed or registered dealer or distributor of diesel motor fuel in the state or province named in item 3above, authorized to import and/or sell in that state or province the diesel product being purchased. This authorization isevidenced by the attached photocopy of my valid distributors or dealers license or letter from the taxing authority of that state orprovince certifying my status as a dealer or distributor.
or
I certify that the state or province named in item 3 above does not license or register dealers or distributors who import into thestate or province and/or sell diesel product that is the subject of this purchase; however, I am licensed with and authorized toconduct business in this state or province as evidenced by the attached photocopy of my valid sales tax, value added tax,corporation tax or business registrat