DYED DIESEL FUEL EXEMPTION CERTIFICATE

DYED DIESEL FUEL EXEMPTION CERTIFICATE
The undersigned buyer hereby certifies that the DYED DIESEL FUEL purchased from WESTERN STATES OIL COMPANY for the period:
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
will be used for the non-taxable purpose specified below (CHECK ONE):

Use on a farm for farming purposesExclusive use of a state or local governmentUse in a vehicle owned by an aircraft museumUse in a boat employed in commercial fishing or transporting persons or property for compensation or hire or any other trade or business, unless the boat is used predominantly for entertainment, amusement, or recreation.Use in a school bus or the exclusive use of a nonprofit educational organizationUse in a qualified local busUse in a highway vehicle that is not registered and is not required to be registered under the laws of any state or foreign country(such as specially designed mobile equipment and construction, mining, manufacturing, processing, farming, drilling, timbering or other such specially designed equipment).Use in a vehicle owned by the United States that is not used on a highwayUse in a vessel of war of the United States or any foreign nationUse other than as a fuel in a propulsion engine of a diesel-powered vehicle or diesel powered boat(such as home heating oil, use in stationary engines, or separately-powered motor to run a refrigeration unit, pump, generator, or mixing unit).
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EIN (Tax Identification or Social Security #)
Signature

Clear
Name

First NameLast Name
Title
Should be Empty:

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