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Department of Taxation and Finance
Statement of Exportation of FT-1003(11/18)
Diesel Motor Fuel by Purchaser
Note: This certificate 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 the photocopy or letter referred to below is attached. This certificate may only be
accepted by a distributor of diesel motor fuel. It cannot be accepted by a retailer of non-highway diesel motor fuel only or a distributor of kero-jet fuel only.
Note: To be completed by the purchaser and given to the seller, who must keep it for at least three years after the date of the sale or, if this is a blanket
certificate, three years after the expiration date.
Name of seller (must be a Distributor of Diesel Motor Fuel) Name of purchaser
Street address Street address
City State ZIP code City State ZIP code
Date of delivery Employer identification number (EIN)
Mark an X in the applicable box:
Single-purchase certificate – Enter the invoice number , delivery ticket number ,
gallons purchased , and the product code (see Publication 902, Product Codes for Fuels).
Blanket certificate – This exemption certificate covers only purchases for export as indicated on each invoice or delivery ticket and
is valid from until it expires at 11:59 PM on December 31 of the same year.
(effective date)
A new Form FT-1003 must be provided to the seller for purchases for export after December 31.
I certify that:
1 I am purchasing diesel motor fuel from the above-named seller, and the diesel motor fuel excise tax, petroleum business tax and prepaid sales
tax are not being passed through to me.
2 I will not subsequently resell, deliver or use this diesel motor fuel in New York State.
3 This diesel motor fuel will be immediately transported from New York State to the state or province of
where it will be either (mark an Xin the applicable box and furnish address if requested):
sold or used at my facilities located at or
street, city, state or province
delivered to my customer’s facility at or
street, city, state or province
delivered directly to consumers outside New York State 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 on line 3 above, it is lawful for me to import diesel motor fuel there and (mark an X in one):
I certify that I am a duly licensed or registered dealer or distributor of diesel motor fuel in the state or province named on line 3 above,
authorized to import and/or sell in that state or province the diesel motor fuel being purchased. This authorization is evidenced by the
attached photocopy of my valid distributor’s or dealer’s license or letter from the taxing authority of that state or province certifying my status
as a dealer or distributor.
or
I certify that the state or province named on line 3 above does not license or register dealers or distributors who import into the state or
province and/or sell diesel motor fuel that is the subject of this purchase; however, I am licensed with and authorized to conduct business in
this state or province as evidenced by the attached photocopy of my valid sales tax, value added tax, corporation tax or business registration
certificate or other authority issued by such state or province.
Certification: I certify that the above statements are true, complete, and correct, and that no material information has been omitted. I make these statements
with the knowledge that willfully providing false or fraudulent information with the intent to evade tax may constitute a felony or other crime under New York
State Law, punishable by a substantial fine and possible jail sentence. I understand that the vendor is required to collect such applicable taxes from me unless
I properly furnish this certificate to the vendor and that the vendor must retain this certificate and make it available to the Tax Department upon request. I also
understand that the Tax Department is authorized to investigate the validity and accuracy of any information entered on this document.
Signature of purchaser or authorized representative Title Date
Evasion of taxes on diesel motor fuel in New York State is a felony, and any person who attempts to use this form to evade the taxes on diesel motor fuel
is liable for statutory penalties as provided by the New York State Sales Tax, Petroleum Business Tax and Motor Fuel Tax Laws and Regulations.
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