Code of Federal Regulations Title 26. Internal Revenue § 26.48.4041–15 Sales to States or political subdivisions thereof

(a) Application of exemption.The taxes imposed by section 4041 do not apply in the case of a sale of any liquid by any person for the exclusive use of any State or any political subdivision thereof, the District of Columbia, or in the case of the use of any liquid by any State or any political subdivision thereof, or the District of Columbia, as a fuel in a motor vehicle, motorboat, or aircraft.

(b) Evidence required to establish exemption.Any vendor claiming exemption under this section shall be prepared to produce evidence that will establish the right to exemption from the tax imposed by section 4041. Generally, orders or contracts of a State or a political subdivision thereof, or the District of Columbia, when signed by an authorized officer thereof will be accepted in support of the exemption. However, in the absence of such orders or contracts, a certificate signed by such an authorized officer that the liquid sold was purchased for the exclusive use of a State or political subdivision thereof, or the District of Columbia, will be acceptable. The certificate shall be in substantially the following form:

(For use by States and local governments. (section 4041(g)(2) of the Internal Revenue Code).)

Date ______, 19__.

I hereby certify that I am ______ of ______ (State or local government) that I am authorized to execute this certificate;  and that

______ the liquid or liquids specified in the accompanying order, or on the reverse side hereof, (or)

______ all orders placed by the purchaser for the period commencing ______ (Date) and ending ______ (Date) (period not to exceed 12 calendar quarters) are, or will be, purchased from ______ (Name of vendor) for the exclusive use of ______ (Governmental unit) of ______ (State or local government).

I understand that the exemption from tax in the case of sales of liquids under this exemption certificate is limited to the sale of articles purchased for the exclusive use of a State, etc. I understand that the fraudulent use of this certificate for the purpose of securing this exemption will subject me and all parties making such fraudulent use of this certificate to a fine of not more than $10,000, or to imprisonment for not more than 5 years, or both, together with costs of prosecution.

Signature ____________________

Address ____________________