New York State Department of Taxation and Finance
                                                                                                                                FT‑1021‑A 
                             Certification for Purchases of                                                                                 (6/12)
                             Non‑Highway Diesel Motor Fuel or
                             Residual Petroleum Product by 
                             Certain Exempt Organizations

This certificate must be completed by the purchaser and given to the seller(see instructions) .
Type or print  
 Name of purchaser                                                            Name of seller

 Address (number and street)                                                  Address (number and street)

  City                                          State ZIP code                City                                        State     ZIP code

  Exempt organization number(from Form ST-119)                                EIN (mark an  X in the appropriate box(es); enter EIN)  
                                                                              Distributor of diesel motor fuel
    Federal employer identification number (EIN)                              Retailer of non-highway diesel motor fuel only
                                                                              Residual petroleum product business
Mark an  Xin the applicable box: 
                                                Single‑purchase certification

  Blanket certification 
Unless this is marked above as a Single-purchase certification, it will be considered part of any order given to the seller by the 
purchaser and will remain in force until revoked by written notice. It covers purchases of the specific product marked below. Use a 
separate Form FT‑1021‑A for each product.
I am purchasing(mark an  X in box 1 or 2)       :

1        Non‑highway diesel motor fuel (complete worksheet below)

2        Residual petroleum product (do not complete worksheet; exempt from petroleum business tax and state and local sales taxes).
         No excise tax is imposed on residual petroleum product.

                                                      Fuel use percentage worksheet
 Mark an  Xin one or more boxes and, if applicable, indicate the percentage. You must be able to substantiate the percentage of fuel 
 used for each purpose. The percentages must total 100%.
 This fuel will be used for:  

              %  Residential heating purposes (exempt from excise tax, petroleum business tax, and state and local sales taxes).

    %  Nonresidential heating purposes, and the purchaser is an organization exempt under:

                        Section 1116(a)(4) (exempt from excise tax, petroleum business tax, and state and local sales taxes).

                        Section 1116(a)(5) (exempt from excise tax and petroleum business tax, but subject to state and local sales  
                        taxes).
                 % Other purposes (explain)
 For purposes other than heating, but for the organization’s exempt purposes (exempt from excise tax and petroleum business tax, but 
 subject to state and local sales taxes, unless otherwise exempt). Note: Fuel used on the public highways, purchased at a filling station, 
 delivered into a tank with a nozzle capable of fueling a motor vehicle, or not used for the organization’s exempt purposes, is subject to 
 excise tax, state and local sales taxes, and petroleum business tax at the highway diesel motor fuel rate, unless otherwise exempt.

Signature 
I certify that the above statements are true and complete, and I make these statements with the knowledge that willfully issuing a false 
or fraudulent certificate with the intent to evade tax is a misdemeanor under New York State Tax Law sections 1812(c)(4), 1812-f(c)(4), 
and 1817(m) and Penal Law section 210.45, punishable by a fine up to $10,000 for an individual or $20,000 or more for a corporation. 
I also understand that the Tax Department is authorized to investigate the validity of exemptions claimed or the accuracy of any 
information entered on this form.
  Signature of purchaser or authorized representative        Title                                                                  Date 

Page 2 of 2  FT‑1021‑A (6/12)
                                                            Instructions
Who may use this form                                                profits derived) to the exercise or performance of its charitable, 
                                                                     educational, or other purpose or function.
This certification may be used only by organizations 
granted exempt organization status under Tax Law, Article 28,        Volunteer fire companies and voluntary ambulance services 
section 1116(a)(4) or section 1116(a)(5). The exempt                 may purchase motor fuel or diesel motor fuel for use in motor 
organization must give its supplier a completed Form FT-1021-A       vehicles exempt from NYS and local sales taxes by giving the 
to purchase non-highway diesel motor fuel or residual petroleum      supplier both a properly completed Form FT-937, Certificate of 
product, without payment of certain taxes. The fuel must be          Exemption for Qualified Hospitals, Volunteer Fire Companies 
used for the exclusive use and consumption by the named              and Volunteer Ambulance Services, and Form ST-119, Exempt 
organization (other than on the public highways of New York          Organization Certificate.
State (NYS)). Note: This certification cannot be used by exempt 
organizations to purchase gasoline.                                  Exempt organizations that use non-highway diesel motor fuel or 
                                                                     residual petroleum product in the production of tangible personal 
Organizations exempt under section 1116(a)(4) include                property for sale by manufacturing, processing, or assembly 
organizations operated exclusively for religious, charitable,        should give the supplier a properly completed Form FT-1012, 
scientific, literary, or educational purposes, or to foster national Manufacturing Certification for Non-Highway Diesel Motor Fuel 
or international amateur sports competition, or for the prevention   and Residual Petroleum Product, for exemption from NYS and 
of cruelty to children or animals.                                   local sales taxes, the diesel motor fuel tax, and the petroleum 
                                                                     business tax.
Organizations exempt under section 1116(a)(5) include posts or 
organizations of past or present members of the armed forces of      Exempt organizations that must pay NYS and local sales taxes 
the United States, or auxiliary units, or societies of, or trusts or may claim a refund of the sales taxes by completing and filing 
foundations for, any of these posts or organizations.                Form FT-500, Application for Refund of Sales Tax Paid on 
                                                                     Petroleum Products.
Sellers                                                              Certain exempt organizations may be able to claim a refund of 
Your sales are subject to the applicable taxes on non-highway        the excise tax on Form FT-946/1046, Motor/Diesel Motor Fuel 
diesel motor fuel or residual petroleum product, unless the          Tax Refund Application.
purchaser gives you a properly completed certification at or 
before the time of delivery. Keep the certification for at least     The exempt organization must use Form TP-385, Certification 
three years from the due date of the return that reports the final   of Residential Use of Energy Purchases, to certify and compute 
purchase of fuel by the exempt organization.                         the percentage of fuel used for residential heating purposes and 
                                                                     nonresidential heating purposes when only one tank is used for 
                                                                     both purposes.
Definitions
Diesel motor fuel is No. 1 diesel motor fuel, No. 2 diesel motor 
fuel, biodiesel, kerosene, fuel oil or other middle distillate and   Need help?
also motor fuel suitable for use in the operation of an engine 
of the diesel type. It does not include any product specifically                  Visit our Web site at www.tax.ny.gov
designated as No. 4 diesel motor fuel.                                            •  get information and manage your taxes online
Non-highway diesel motor fuel is any diesel motor fuel that is                    •  check for new online services and features
designated for use other than on a public highway (except for the 
use of the public highway by farmers to reach adjacent lands),          Telephone assistance
and is dyed diesel motor fuel.
                                                                        Miscellaneous Tax Information Center:  (518) 457-5735
Highway diesel motor fuel is any diesel motor fuel which is not 
non-highway diesel motor fuel.                                          To order forms and publications:                (518) 457-5431
Residual petroleum product includes the topped crude of 
refinery operations consisting of No. 5 fuel oil, No. 6 fuel oil,       Text Telephone (TTY) Hotline (for persons with hearing 
                                                                                  and speech disabilities using a TTY): If you have 
bunker C, and that special grade of diesel product specifically                   access to a TTY, contact us at (518) 485-5082. 
designated as No. 4 diesel fuel that is not suitable for use in the               If you do not own a TTY, check with independent 
operation of a motor vehicle engine.                                              living centers or community action programs to find 
Dyed diesel motor fuel is diesel motor fuel that has been dyed                    out where machines are available for public use.
in accordance with and for the purpose of complying with the 
provisions of 26 USC 4082(a).                                           Persons with disabilities: In compliance with the 
                                                                                  Americans with Disabilities Act, we will ensure 
                                                                                  that our lobbies, offices, meeting rooms, and other 
General information                                                               facilities are accessible to persons with disabilities. If 
All non-highway diesel motor fuel and residual petroleum                          you have questions about special accommodations 
product must be delivered to the exempt organization’s qualifying                 for persons with disabilities, call the information 
premises and used for residential heating or for the exempt                       center.
purposes of the organization. The non-highway diesel motor fuel 
may not be purchased at a filling station or delivered into a tank 
that can fuel a motor vehicle. 
This certification may not be used for purchases of fuel for use in 
unrelated business activities. An exempt organization is engaged 
in unrelated business activities if the trade or business regularly 
carried on by the organization is not substantially related (aside 
from its need for income or funds or the use it makes of the