phillips 66 coJ
FEDERAL EXCISE TAX EXEMPTION CERTIFICATE
CUSTOMER
NUMSER(S); —
CUSTOMER NAME
AND ADDRESS: —
Date
® BLANKET EXEMPTION CERTIFICATE
Period / Ja. r.. `-x Ahrough
❑ UNIT EXEMPTION CERTIFICATE
(Complete sales detail on reverse side'•)
Please complete the appropriate exemption, Insert registry number where applicable, and complete signature section.
The undersigned purchaser claims exemption from tax Imposed under the Internal Revenue Code of 1954 as amended:
® Exclusive use of a state or local government preludes public schools) or the District of Columbia. Registry No.
(If registered)
❑ Exclusive use by Indian tribal government or subdivision of such government when approved by Treasury Department.
Delegated tribe's name
❑ Exclusive use In Its educational activities of a school, operated as an activity of a church or other organization described In Sec-
tion 501(a) (3) of the Internal Revenue Code of 1954, which normally maintains a regular faculty and curriculum and normally has
a regularly enrolled body of pupils or students, In attendance at the place where Its eductlonal activities are regularly carried on.
Registry No.
❑ Exclusive use of a nonprofit educational organization which has received a determination letter (or a ruling) from the Internal
Revenue Service holding the organization to be exempt from Income tax as an organization described in Section (170) (b) (1) jA) III)
that Is exempt from Income tax under Section 501(a) of the Internal Revenue Code (or has received adetermination letter (or ruling)
under corresponding provisions of prior revenue laws). The date of such determination letter (or ruling) Is and
such determination letter (or ruling) has not been withdrawn or revoked. Registry No.
❑ For vessels or aircraft:( ) Engaged in foreign trade (If aircraft, show country of registry) ' ( ) Engaged in
trade between the U.S. and Its possessions (If aircraft, show country of registry) ; ( ) For vessels engaged In
trade between the Atlantic and Pacific ports of the U.S.; ( ) For vessels employed In the fisheries or whaling business; ( ) For vessels or
aircraft of war of the U.S. or a foreign nation.
❑ For export or for resale for export. Registry No. (Number not required from foreign purchaser).
(Proof of export must be furnished within six months)
❑ Producer of gasoline (including a wholesale distributor). Registry No.
❑ Producer purchasing for purpose of blending gasohol. Registry No. (Complete Gasoline Sales
Metall on back of this Form on gallons to be refunded) •-
❑ Pipeline Common Carrier (Used exclusively to indemnity shippers for In -transit losses) Registry No.
❑ For use in further manufacturer. Registry
❑ Other exempt use. (Describe)'
The undersigned understands that the fradulent use of this certificate for the purpose of securing this exemption will subject him/her and all gull•
ty parties to a fine of not more than $10,000, or to Imprisonment for not mare than five years, or both, together with cost of prosecution. The
undersigned understands that if the articles are used or disposed of otherwise than as stated on the exemption certificate, such fact must be
reported to the namufacturer at once.
It Is agreed by the undersigned that If the articles purchased tax free under this exemption certificate are used or disposed of otherwise than as
herein specified, or If for any reason this certificate is rejected by the Federal Government, the vendee will pay to the Phillips 65 Company the tax,
Including any Interest and penalty, on such articles or will reimburse the Phillips 56 Company any tax, Including any interest and penalty, assess-
ed by the Federal Government.
• Registry number must be Inserted. Only sales to state (including Indian Tribal governments), or local government and foreign export pur-
chasers do not require registry number.
If last seller (ultimate vendor) Is other than Phillips SS Com-
pany, reverse side must be completed. If last seller did not
purchase direct from Phillips 50 Company, intermediate
vendor endorsements) must also be completed.
FORM 407M 1.65
RC — ORIGINAL
D
. lName of PurchaaerL
✓
By: L
aSigna uro of Authorized Officer or Agent)
G�er�
/ (Title of Officer orApsne /
'e{ _ 6%y0 a.�3e
(Complete Milling Addreaa Of Purchaser)