Certificate of State or Local Government Use

Certificate of State or Local Government Use or Nonprofit Educational Organization- Gasoline

Calendar Year 2025
To support vendor's claim for a credit or payment for the Federal Excise Tax on tax free sales of gasoline under article 6416(a4) or 6427 respectively, of the Internal Revenue Code by the ultimate vendor(s):

Keystone Cooperative, Inc
770 N. High School Road
Indianapolis, IN 46214

The undersigned ultimate purchaser ("buyer") hereby certifies the following under penalties of perjury:
Buyer will use the gasoline or aviation gasoline to which this certificate relates:

For the exclusive use of a state or local government unitFor the exclusive use of a nonprofit educational organization
Certificate Type:

This is a single purchase certificateThis certificate covers all purchases under a specific entity, or account or order number
Invoice or Ticket Number:
Number of Gallons:
Effective Date:

MonthDayYear
Date
Expiration Date:

MonthDayYear
Date
Buyer Account Number(s):
For multiple accounts, add a comma between each account #
Buyer's Name on Account:
If buyer does business with vendor under more than one account, either submit a certificate for each account or enter each account number in the above field. Note that separate certificates are necessary if accounts have separate Federal ID Numbers.

Buyer agrees to provide a new certificate to the vendor if any information in this certificate changes.

Buyer understands that by signing this certificate, Buyer is certifying it has not and/or will not claim any credit or payment of the Federal Excise Tax on the fuels to which this certificate relates and gives up any right to claim such credit or payment.

Buyer understands if Buyer uses the fuels to which this certificate relates for a purpose other than stated in the certificate, Buyer will be liable for any Federal Excise Taxes thereby due. Buyer also understands that fraudulent use of this certificate may subject Buyer and all parties making such fraudulent use of this certificate to a fine and/or imprisonment, plus cost of prosecution.
Name of Buyer (purchasing organization):
Buyers Federal ID or EIN:
Address of Buyer:
Name of Person Signing:
Title of Person Signing:
Signature:

Clear
Signature Date:

MonthDayYear
Date
Email:
example@example.com
Should be Empty:

Certificate of State or Local Government Use or Nonprofit Educational Organization- Gasoline