Page 109 - IRS Business Tax Credits Guide

Page 30 of 38
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
Page 4 Fileid: … ns/i8933/202212/a/xml/cycle06/source 12:51 - 5-Jan-2023
No

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model Certificate UTZ

Utilization Certification (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name and location of qualified carbon oxide capture facility (if supplier supplied any qualified carbon oxide)

Part III. Information About You and Each of Your Suppliers of Qualified Carbon Oxide
Section 1—Information about you, the owner or lessee of the utilization project:
Type of industrial facility at which the supplier captured its qualified carbon oxide

manner required under section 45Q(f)(5) and the underlying regulations?
the same, there must be a binding written contract between the entities

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should agree with the figure reported in Table 3) . . . . . . . LCA (metric tons should agree with the figure reported in Table 3) . an LCA (metric tons should be part of the figure in Table 3)
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Name . . . . . . Address . . . . . EIN Supplier's name Supplier's EIN
1 2 3 4 5 6 7 8 9 10 11 12 13 14
-30- Instructions for Form 8933 (Rev. 12-2022)