Page 104 - IRS Business Tax Credits Guide

12:51 - 5-Jan-2023
Page 25 of 38
Fileid: … ns/i8933/202212/a/xml/cycle06/source
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Page 2
Enhanced Oil Recovery Operator Certification (continued)
Table 2 — Information About Suppliers of Qualified Carbon Oxide
Check if
supplier
Qualified Location of capture Check if supplier provided
Name of
carbon oxide Name EIN capture facility facility provided any qualified any
supplier (county, state) carbon oxide nonqualified
carbon
oxide
1
2
3
20 Complete Table 3 below using information that conforms to all applicable EPA filings and certified ISO 27916 documentation if it was used to
demonstrate secure storage. If there are more than four owners of the EOR project or three suppliers of qualified carbon oxide, prepare a
separate table that includes all relevant information and attach it to this model certificate.
21 Check here to attest that all figures in Table 3 conform to all applicable EPA filings and certified ISO 27916 documentation .
Table 3 — Information About Enhanced Oil Recovery
Qualified carbon Qualified carbon Qualified carbon Total qualified All other Total metric tons for all
oxide supplier oxide supplier oxide supplier carbon oxide from suppliers of carbon oxide suppliers
number 1 number 2 number 3 all suppliers nonqualified
carbon oxide
(H) (I)
Metric Metric (L) Metric (M) Metric
tons
(D)
tons
(J)
(K)
(E)
(F)
(G)
(C)
(B)
(A) EOR Metric Metric Metric Metric Metric Metric delivered stored Metric Metric tons tons stored
project tons tons tons tons tons tons (add (add tons tons delivered (add
owner delivered stored delivered stored delivered stored columns columns delivered stored (add columns columns (I)
(C),
(B), (D), (E), and (H) and (J)) and (K))
and (F)) (G))
1
2
3
4
5 Total (add
lines 1
through 4)
Under penalties of perjury, I attest that I am an officer of the company that’s the operator of the subject EOR project or that I have been designated
by the operating interest owners to prepare and submit this certificate to the IRS on their behalf. I further attest that the above information is true and
correct.

Signature and date signed

Printed or typed name of person signing this report

Title

Company's name and EIN

Model Certificate EOR‐Operator

Instructions for Form 8933 (Rev. 12-2022) -25-