Reso 2021-3185 - Laserfiche WebLink

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CERTIFICATE OF BUYER OF TAXABLE FUEL FOR USE BY A STATE OR NONPROFIT EDUCATIONAL ORGANIZATION (To support credit card issuer's claim for a credit, refund, or payment under § 6416(a) (4) (B) or § 6427(I) (6) (D) of the Internal Revenue Code.) WEX Account Number (if known): Federal Tax Identification Number: Certification: The undersigned hereby certifies under penalties of perjury that I am the (Title of Officer): Of (Certifying Entity): Entity Physical Address: Entity Phone Number: And that I am authorized to execute this certificate and that all purchases, are, or will be, purchased using a credit card issued by (Credit Card Issuer): WEX BANK 7090 Union Park Center, Suite 350 Midvale, UT 84047 Buyer will use the taxable fuel to which this certificate relates for the exclusive use of: (check one) ❑ State government ❑ American Red Cross or Blood Collection Center ❑ Local government ❑ Indian Tribe ❑ Public nonprofit educational organization ❑ Volunteer Fire/Rescue ❑ Private nonprofit educational organization ❑ Foreign Diplomat (they must provide a copy of their PID Card) and it applies to all exempt purchases of gasoline and diesel fuel, if eligible, using charge cards issued by the Credit Card Issuer named above. Information including the nature and quantity of each purchase of gasoline and diesel fuel (the subject of this Certificate) are evidenced by periodic reports provided by WEX BANK, the above- named Credit Card Issuer. Certification will be valid for twenty-four consecutive calendar months commencing upon completion and remittance of this Certificate. WEX Inc. may extend the certificate period upon its discretion for an additional period not to exceed four months. I understand that by signing this certificate, I, as an authorized representative of the entity named above, give up our right to claim a credit or payment for the taxable fuel purchased with the credit card to which this Certificate relates. I understand that the exemption from tax, in this case of sales of articles under the exemption Certificate, is limited to the sale of articles purchased for our exclusive use. I understand that the fraudulent use of this Certificate for the purpose of securing this exemption will subject us, and all parties making such fraudulent use of this Certificate, to fines or imprisonment, or both, together with the costs of prosecution. The parties agree that a signed transmission shall be considered valid for purposes of this certification and that the parties hereby waive any claim that a transmission does not satisfy the requirements_ of a signature or writing under _ applicable law. Authorized Signature Printed Signature Title Date Email or FAX completed forms to TaxExemptForms@WEXINC.Com or 1-207-523-7104 INTERNAL USE ONLY Sales Representative: MASTER AGREEMENT No. 00819 — FLEET CARD SERVICES PAGE 47 OF 138