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                                            Form
                                                      Fuel Tax Exemption Certificate
                      2992                            Sales to U.S. Government

Fuel retailers in Missouri making sales to the U.S. Government may make such sales without charging fuel tax if the 
retailer has obtained a signed exemption certificate. This certificate must be maintained in the retailer’s files and must be 
updated every three years.

                                            Seller’s Name                                                                               Federal Employer Identification or Social Security Number

                                            Address 
           Seller 
                                Information City                                                   State      ZIP Code                Telephone Number

                                                                                                                             (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

                                            Purchaser’s Name                                                                             Federal Employer Identification or Social Security Number

                                            Address 

           Purchaser  
                                Information City                                                   State      ZIP Code                Telephone Number

                                                                                                                             (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

 r  Motor Fuel Sold To U.S. Government

 Government Agency Name                                                                                   Exempt Use 

 This Exemption is for: (select one)   
                                                               r  All motor fuel purchased                                   r  __________________ Gallons

                                            I hereby certify, under penalty of perjury, that the motor fuel purchased will be used in the exempt manner stated above and defined by the 
                                            statute quoted below. The invoice or sales slip for each individual purchase claimed under this exemption certificate will be signed and dated 
                                            and such exemption will be updated every three years with the retailer.
                                            I further certify under penalty of perjury that if any of the motor fuel on said invoice or sales slip is not used as certified above, which will make 
                                            such fuel subject to the motor fuel tax, I will so notify the seller and pay the tax thereon. Should I not so notify the seller, then I am liable for 
                                            tax, penalty and interest on such purchase, pursuant to the provisions of Chapter 142, RSMo.
                      Signature             Printed Name of Authorized Purchaser or Purchaser’s Agent                         Title

                                            Signature                                                                         Date (MM/DD/YYYY)
                                                                                                                              ___ ___ /___ ___ /___ ___ ___ ___

This exemption certificate must be completed and maintained in the retailer’s files to substantiate sales made to the U.S. 
Government.

Missouri law, Section 142.815.2(3), RSMo, allows exempt sales to the U.S. Government. The seller must obtain a signed 
exemption certificate from the purchaser (U.S. Government). The signed certificate must be maintained by the retailer, 
and must be updated every three years. The retailer must keep the original, signed certificate in its files to support sales 
made without state fuel tax. A copy of the certificate may be given to the customer or purchaser.

                                                                                                                                                       Form 2992 (Revised 04-2014)
Mail To:                                    Taxation Division                 Phone:  (573) 751-2611                                                   
                                            P.O. Box 300                      TTY:  (800) 735-2966                            Visit http://dor.mo.gov/business/fuel/
                                            Jefferson City, MO 65105-0300     Fax:  (573) 522-1720                                   for additional information.
                                                                              E-mail:  excise@dor.mo.gov