Certificate of State or Local Government Use - Diesel 2025 Logo
  • Certificate of State or Local Government Use or Nonprofit Educational Organization- Diesel

    Calendar Year 2025
  • To support vendor's claim for a credit or payment for the Federal Excise Tax on tax free sales of Diesel Fuel and/or Kerosene under article 6416(a)(4) 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:

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  • 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.

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