Page 115 - IRS Business Tax Credits Guide

12:51 - 5-Jan-2023
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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 3
Recapture Certification (continued)

Under penalties of perjury, I attest that I am an officer of the company that’s the operator of the subject geologic disposal site or the subject EOR
project or 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 qualified carbon oxide sequestration credit recapture information is true and correct.

Signature and date signed

Printed or typed name of person signing this report

Title

Company's name and EIN

Part III. Determination of Recaptured Qualified Carbon Oxide for Supplier
Part III will be prepared by each owner of the disposal site or EOR project during the current and THREE previous calendar years. Part III will be
used to determine the amount of qualified carbon oxide sequestration credit that needs to be recaptured. A separate Part III should be completed for
each supplier of qualified carbon oxide during the current and THREE previous calendar years and a copy should be given to each supplier.

Information about you, the owner of the EOR project:
1 Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 EIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Information about suppliers who supplied carbon oxide during any of the THREE previous calendar years. COMPLETE A PART III FOR
EACH SUPPLIER:
4 Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 EIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Name and location of carbon oxide capture facility (if supplier supplied any qualified carbon oxide) . . . . . .
7 Type of industrial facility at which the supplier captured its qualified carbon oxide . . . . . . . . . . . . . . . . .
8 Complete Table 5 using information from Table 3 of Model Certificate EOR for the previous THREE calendar years. Complete a separate Table
5 for each supplier of qualified carbon oxide during the previous THREE calendar years. If one supplier supplied qualified carbon oxide from
multiple facilities, complete a Table 5 for each facility.

Model Certificate RECAPTURE

-36- Instructions for Form 8933 (Rev. 12-2022)