New York State Department of Taxation and Finance
                                                                                                                                   FT-1003
                                    Statement of Exportation of                                                                                               (8/12)
                                    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                                                                   Federal employer identification number (if any)

Mark an  Xin 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 thereand (mark an Xin 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 understand that my signature on this certificate authorizes representatives of the New York State Department of Taxation and Finance to 
inspect my books and records relating to this transaction and to inspect my facilities located outside of New York State in order to verify the statements made 
on this certificate. I also understand that the Tax Department may divulge the details of this transaction to the taxing authorities of the state or province to 
which the diesel motor fuel is being exported.
 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.

Page 2 of 2 FT-1003 (8/12)

                                                        Instructions
This certificate is for use by persons and businesses          Information concerning quarterly wages paid to employees 
purchasing diesel motor fuel in New York State for             is provided to certain state agencies for purposes of 
immediate export out of New York State for sale or use by      fraud prevention, support enforcement, evaluation of the 
the purchaser outside of New York State. The purchaser         effectiveness of certain employment and training programs 
may buy diesel motor fuel exempt from the state diesel         and other purposes authorized by law.
motor fuel excise tax, the petroleum business tax and the 
                                                               Failure to provide the required information may subject you 
prepaid sales tax or actual retail sales tax provided the 
                                                               to civil or criminal penalties, or both, under the Tax Law.
purchaser completes this certificate in its entirety, provides 
the certificate to the seller prior to or at the time of       This information is maintained by the Manager of Document 
delivery, and provides evidence that the purchaser meets       Management, NYS Tax Department, W A Harriman Campus, 
one of the following conditions:                               Albany NY 12227; telephone (518) 457-5181.

1.  If the state or province where the diesel motor fuel is     Need help?
 being exported requires a license or registration to               Visit our Web site at www.tax.ny.gov
 import and/or sell the specific diesel motor fuel so               •  get information and manage your taxes online
 exported, the purchaser must provide evidence of being             •  check for new online services and features
 a registered distributor or dealer of the specific diesel 
 motor fuel in the state or province of export.                     Telephone assistance
                                                               Miscellaneous Tax Information Center:         (518) 457-5735
 or
                                                               To order forms and publications:              (518) 457-5431
                                                               Text Telephone (TTY) Hotline (for persons with
2.  If the state or province where the diesel motor fuel         hearing and speech disabilities using a TTY):  (518) 485-5082
 is being exported does not require a license or                    Persons with disabilities: In compliance with the 
 registration to import and/or sell the specific diesel             Americans with Disabilities Act, we will ensure that our 
 motor fuel so exported, the purchaser must provide                 lobbies, offices, meeting rooms, and other facilities are
 evidence of being otherwise authorized to conduct             accessible to persons with disabilities. If you have questions 
                                                               about special accommodations for persons with disabilities, call 
 business in the state or province of export.                  the information center.

The purchaser must provide a photocopy of his or her 
dealer or distributor license or evidence of being otherwise 
licensed to conduct business in such state or province.

Other persons and businesses purchasing diesel motor fuel 
in New York State for export are required to pay the state 
diesel motor fuel tax, the petroleum business tax and the 
sales tax on their purchases. Depending on the subsequent 
use and/or sale of the diesel motor fuel outside of New York 
State, the purchaser may be entitled to a refund or credit of 
the taxes paid.
Diesel motor fuel is No. 1 diesel fuel, No. 2 diesel fuel, 
biodiesel, kerosene, fuel oil or other middle distillate and 
also motor fuel suitable for use in the operation of an 
engine of the diesel type. It does not include any product 
specifically designated No. 4 diesel fuel.

Privacy notification
The Commissioner of Taxation and Finance may collect and 
maintain personal information pursuant to the New York 
State Tax Law, including but not limited to, sections 5-a, 
171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 
1415 of that Law; and may require disclosure of social 
security numbers pursuant to 42 USC 405(c)(2)(C)(i).
This information will be used to determine and administer 
tax liabilities and, when authorized by law, for certain tax 
offset and exchange of tax information programs as well as 
for any other lawful purpose.