Gasoline Use Tax Exemption Certificate

Gasoline Use Tax Exemption Certificate

Indiana Department of Revenue - Form GT-105
Purchasers located inside and outside Indiana may use this certificate. The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for purchases from Indiana vendors. This exemption certificate may only be used for the purchase of gasoline from a fuel distributor. Purchaser must be registered with the Department of Revenue or the appropriate taxing authority of the purchaser’s state of residence.

Gasoline use tax must be charged unless all information in each section is fully completed by the purchaser. Purchasers not able to provide all required information must pay the tax and may file a claim for refund (Form GA-110L) directly with the Department of Revenue.
SECTION 1
Name of Purchaser:*
Address:*

Business Address

Street Address Line 2

CityState

ZIP Code
Purchaser must provide minimum of one ID number below.

Provide your Indiana Registered Retail Merchant’s Certificate TID and LOC Number as shown on your Certificate.
TID Number (10 digits):
LOC Number (3 digits):
If not registered with the Indiana DOR, provide your State Tax ID Number from another State
State ID Number:
State of Issue:

SECTION 4
Purchaser must indicate the type of exemption being claimed for this purchase (check one or explain).

NOTE: This certificate may not be used to claim a sale for resale.
Exemption Being Claimed:*

Sale of gasoline to be used directly in direct production.Sales of gasoline predominately used (greater then 50 percent) in providing public transportation - provide USDOT Number. A person or corporation who is hauling under someone else’s motor carrier authority, or has a contract as a school bus operator, must provide their SSN or FID Number in lieu of a State ID Number in Section 1.Sales of gasoline to persons, occupationally engaged as farmers, to be used directly in production of agricultural products for sale. Note: A farmer not possessing a State Business License Number may enter a FID Number or a SSN in lieu of a State ID Number in Section 1.Sales of gasoline to Indiana Governmental Units (agencies, cities, towns, municipalities, public schools, and state universities).Sales of gasoline to the United States Federal Government - show agency name. Note: A U.S. Government agency should enter its Federal Identification Number (FID) in Section 1 in lieu of a State ID Number.Other - explain.
USDOT Number:*
Agency Name:*
Other - Explain:*

SECTION 5
I hereby certify under the penalties of perjury that the gasoline purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act, Indiana Code 6-2.5.
I confirm my understanding that misuse, (either negligent or intentional), and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represent to the imposition of tax, interest, and civil and/or criminal penalties.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*
Title:*
The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser.

Seller must keep this certificate on file to support exempt sales.
Should be Empty: