Form Op-218 - Petroleum Products Gross Earning Tax
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1Form OP-218
Department of Revenue Services
State of Connecticut
25 Sigourney Street
Petroleum Products Gross Earnings Tax
Hartford CT 06106-5032
(Rev. 07/07)
This Certification Applies to Products Purchased in Connecticut But Sold Out of State
Name of Exporting Company
Address
City or Town
State
ZIP Code
Purchased From (Name of Distributor)
Period Covered
State Shipped To
Exporting Company’s Certification
This certifies that the exporting company listed above has sold the petroleum products listed below, in the quantities shown, for sale or use
outside the State of Connecticut. These products were purchased in the State of Connecticut and the 7% petroleum products gross earnings
tax was paid on the purchase price listed below. Therefore, the exporting company listed above is requesting payment in the amount of
$ _________________________________________________________ ,which represents the gross earnings tax paid on these products.
Type of Petroleum Product(s)
Gallons
Purchase Price
$
Total Purchases
$
Petroleum Products Gross Earnings Tax Paid
$
Total Purchases x 7%
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) or document and, to the
best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to the Department
of Revenue Services (DRS) is a fine of not more than $1,000 or imprisonment for not more than one year, or both.
Signed
T i t l e
Date
Endorsement by Distributor: Do not complete this section if you are the distributor who made the first sale in
Connecticut of the petroleum product(s) listed above. See note below.
To ________________________________________________________________________________________________________________
(Name of Distributor)
This certifies that the information shown above is correct. A credit in the amount of $ ____________________________________________
has been made to ____________________________________________________________________________________________________
(Name of Exporting Company/Distributor)
We request reimbursement of the petroleum products gross earnings tax paid as detailed below:
Purchase price: $ __________________________________________________________
Gross earnings tax refund requested: $ ________________________________________
_________________________________________________________________________________________________________________
Name of Distributor
S i g n e d
T i t l e
D a t e
Note to distributor who made the first sale in Connecticut of the petroleum product(s) listed above: You must attach a copy of this form to
your Form OP-161, Petroleum Products Gross Earnings Tax Return, to support the deduction claimed on Line 15 of the return.
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