Washington Carbon Fee Exemption/Reimbursement Form - Valley Wide Cooperative Energy

Washington Carbon Fee Exemption/Reimbursement Forms

Washington Climate Commitment Act Resources

Please complete the Washington CCA Ag Exempt Certificate by clicking the button below.

HOW DO I KNOW IF I AM EXEMPT?

Washington Dept. of Ecology Exemption Certificate

Note: After submitting these forms, please remember to check your email and verify it in order for us to receive your form. If you do not receive the verification message, please double-check your spam or junk mail folders.

This form will be retained in your customer file with Valley Wide Cooperative and should only be submitted once, pending any amendments from the WA Dept. of Ecology.

After submitting the certificate, please let your Valley Wide representative (Sales Person, Office Staff, Driver, etc.) know that the delivery request is for fuel exempt from CCA fees when placing an order.

Exemption/Reimbursement Form

The form below must be completed for every fuel exemption or reimbursement request.

Understanding My Statement

The fuel type purchased with a CFN card at a Valley Wide Cooperative station is identified by the last two digits in the description line. See example and chart below.

Account Number (must have a Valley Wide account number)*

Full Name*

Business Name (optional)

Email*

Month that exempt fuel was purchased?*

Product Purchased 1:*

Total Gallons Purchased*

Product Purchased 2:

Total Gallons Purchased

Product Purchased 3:

Total Gallons Purchased

Product Purchased 4:

Total Gallons Purchased

Comments

Do you have a Washington Dept. of Ecology Exemption Certificate on file with Valley Wide Cooperative?*
YesNo

Is this request is in compliance with the "Fuel used for Agricultural Purposes" and "Transporting Agricultural Products" forms?*
YesNo