Federal Certificate of Farmer Or State Or Local Government Unit

FEDERAL CERTIFICATE OF STATE OR LOCAL GOVERNMENT USE of DIESEL FUEL and GASOLINE

(To support vendor’s claim for credit or payment under Sections 6427 and 6416(a)(4)of the Internal Revenue Code)

Vendor: UNION DISTRIBUTING COMPANY FEIN: 86-0556151 Address: 622 S 56th Avenue UV#: 2005-000009 Phoenix, Arizona 85043-4622 FAX: 602-484-9038

The undersigned buyer (“Buyer”) hereby certifies the following under penalties of perjury that the buyer will use the diesel, kerosene, gasoline, or aviation gasoline to which this certificate relates for the exclusive use of a state or local government, or the District of Columbia.

This certificate applies to the following (Check one and complete as applicable):

A. Single purchase covering invoice or delivery ticket number ______and number of

undyed exempt gallons ______or;

B. All exempt purchases under account number(s)

Effective date: January 1, 2009 Expiration date: December 31, 2009 (Expiration date not to exceed 1year after the effective date)

Buyer Information Buyer will provide a new certificate to the seller if any information in this certificate changes.

Buyer understands that by signing this certificate, Buyer gives up its right to claim a credit or payment for the diesel or gasoline or aviation gasoline to which this certificate relates.

Buyer acknowledges that it has not and will not claim any credit or payment for the diesel fuel, kerosene, gasoline, and aviation gasoline to which this certificate relates.

If buyer uses the gasoline, aviation gasoline, diesel, or kerosene to which this certificate relates for a purpose other than stated in this certificate, buyer will be liable for tax.

Buyer understands that the fraudulent use of this certificate may subject buyer and all parties making such fraudulent use of this certificate to a fine or imprisonment, or both, together with the cost of prosecution.

Signature of Buyer Legal Name of Buyer or Entity or Organization

Printed or Typed Name of Person Signing Address of Buyer

Title of Person Signing Federal Identification # (FEIN)

Date Signed Telephone Number of Buyer

D:\Docs\2017-12-14\04fb5354651aa2bacecbe4059daeb50b.doc