Catalog Number 16984Z www.irs.gov
Form
928 (Rev. 9-2017)
Form 928
(September 2017)
Department of the Treasury - Internal Revenue Service
Taxable Fuel Bond
(For use to post bond under section 4101)
OMB Number
1545-0725
Check the boxes that apply
This is an Original Bond Strengthening Bond Superseding Bond
This bond is for Gasoline Diesel Fuel Kerosene excise tax
Enter the effective date of bond issued
Enter the bond number
Part I - Bonding
Bond is given by
(Name)
( )
(Telephone number)
(Address)
as principal and
(Name)
(Address)
as surety. As principal and surety, we are obligated to the United States in the amount of
dollars ($
). We also jointly and severally obligate our heirs, executors, administrators, successors, and assigns for the
payment of this amount.
The bond ensures payment of the tax imposed on fuel under section 4041(a)(1) or 4081 of the Internal Revenue Code. The conditions
of the bond are that the principal and the surety agree that:
1. The principal will not attempt to defraud the United States of any tax under section 4041(a)(1) or 4081;
2. The principal will file all returns and statements as required by law or regulations;
3. The principal will pay all taxes including any penalty and interest charges; and
4. The principal will comply with all other requirements of the law and regulations regarding tax under section 4041(a)(1) or 4081.
The surety will be granted relief from liability under the bond at any time, provided the surety notifies the principal and the Internal
Revenue Service in writing at least 60 days before the date on which the surety wants to be relieved of liability. If the notice is given by
an agent of the surety, the notice must be accompanied by a power of attorney or a verified statement that a power of attorney is on file
with the Internal Revenue Service.
If this notice is given, the principal’s rights under the bond will end on the date given in the notice, unless the notice is later withdrawn in
writing, or unless the principal’s rights are supported by other bonds. The surety will be relieved from any liability for acts that occur
after the date given in the notice but will remain liable for any unpaid tax and any penalties and interest incurred by the principal before
the bond was canceled, unless the principal pays the tax, penalties, and interest.
Part II - Signature
Under penalties of perjury, I declare that I have examined this form and any accompanying statements, and to the best of my
knowledge and belief, they are true, correct and complete.
Signature of Principal and Surety
Signature of principal Name (type or print) Date
Signature of surety Name (type or print) Date
Part III - Approval by Internal Revenue Service
Bond approved (date signed) Registration number
Authorized Official signature Title
Name (type or print)
Authorized Official: Send copy of approved form to principal shown above.
dd mmm yyyy
click to sign
signature
click to edit
click to sign
signature
click to edit
dd mmm yyyy
dd mmm yyyy
Page 2
Catalog Number 16984Z www.irs.gov
Form
928 (Rev. 9-2017)
Instructions for Form 928, Taxable Fuel Bond
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
Use this form to post bond required under section 4101,
Registration and bond.
Who Must File
This form must be completed by any person required by the
Internal Revenue Service to post bond as a condition of
registration, or to retain its existing registration, on Form 637,
Application for Registration, (For Certain Excise Tax Activities),
for purposes of the excise tax imposed on gasoline, diesel fuel or
kerosene.
Where To File
File Form 928 in duplicate with the IRS employee who required
the posting of the bond.
Qualifying Sureties
The surety on the bond must be listed in the Department of the
Treasury Circular 570 as an acceptable surety or reinsurer on
Federal bonds.
Amount of Bond
Taxable Fuel — Generally, the amount of bond must be in an
amount that the Internal Revenue Service determines will ensure
timely collection of the taxes imposed by sections 4041(a)(1) and
4081, taking into account the applicant’s or existing registrant’s
financial capabilities, tax history, and expected liability under
sections 4041(a)(1) and 4081. The Internal Revenue Service
may increase or decrease the amount of the required bond to
take into account changes in the applicant’s or existing
registrant’s financial capabilities, tax history, and expected
liability under sections 4041(a)(1) and 4081. However, in no case
may the amount of the bond be greater than the amount that the
Internal Revenue Service determines is equal to —
(a) The applicant’s or existing registrant’s expected tax liability
under sections 4041(a)(1) and 4081 for a representative 6-
month period (as determined by the Internal Revenue
Service); and
(b) In the case of a terminal operator, the expected tax liability of
persons other than the terminal operator under section 4081
with respect to taxable fuel removed at the racks of its
terminals (determined as if all removals of taxable fuel were
taxable) during a representative 1-month period (as
determined by the Internal Revenue Service).
Who May Sign as Principal
The bond must be signed by:
• The individual, if the applicant or existing registrant, is an
individual,
• The president, vice president, or another principal officer, if
the applicant or existing registrant, is a corporation,
• A responsible and authorized current member or officer
having knowledge of the organization’s affairs, if the
applicant or existing registrant, is a partnership or other
unincorporated organization, or
• The fiduciary, if the applicant or existing registrant, is a trust
or estate.
Period of Bond
The liability stated on the bond is a continuing one. It is not made
for any fixed period of time. If the quarterly liability for excise tax
that would be imposed on gasoline, diesel fuel or kerosene is
increased or decreased, contact the Internal Revenue Service
immediately after the quarter to see if a strengthening or
superseding bond is necessary. The bond may also have to be
changed if there is a substantial change in ownership or
management of the business.
Strengthening or Superseding Bond
The Internal Revenue Service may require a strengthening or
superseding bond if:
• It is necessary to ensure collection of the taxes imposed
under sections 4041(a)(1) and 4081, or
• The volume of fuel removed or sold in any month is greater
than the volume on which the existing bond is based.
A “strengthening bond” is an additional bond you give to increase
the amount of your existing bond. A “superseding bond” is a new
bond that takes the place of an existing bond. If you do not
submit a strengthening or superseding bond when required, your
registration may be suspended or revoked.
Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal
Revenue laws of the United States. You are required to give us
the information. We need it to ensure that you are complying with
these laws and to allow us to figure and collect the right amount
of tax.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is:
Recordkeeping . . . . . . . . . . . 1 hr., 55 min.
Learning about the law or the form . . . . . . . 18 min.
Preparing, copying, assembling, and
sending the form to the IRS . . . . . . . . 20 min.
If you have comments concerning the accuracy of these time
estimates or suggestions for making this form simpler, we would
be happy to hear from you. You can write to both the Internal
Revenue Service, Washington, DC 20224, Attention: IRS
Reports Clearance Officer, T:FP; and the Office of Management
and Budget, Paperwork Reduction Project (1545-0725),
Washington, DC 20503. DO NOT file this form with either of
these offices. See Where To File.
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