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Form Au-477 - Aircraft Owner Or Operator Declaration Motor Vehicle Fuels Tax Exemption Form - State Of Connecticut - Department Of Revenue Services

Department of Revenue Services

State of Connecticut

25 Sigourney Street

Form AU-477

Hartford CT 06106-5032

Aircraft Owner or Operator Declaration

(Rev. 01/02)

Motor Vehicle Fuels Tax Exemption

Statutory Authority: Conn. Gen. Stat. §12-458(a)(3)(K)

I am over eighteen years of age.

I am purchasing fuel that will be used exclusively for aviation purposes . For purposes of this

declaration, aviation purposes means for the purpose of powering an aircraft or an aircraft engine.

(Aircraft, as defined in Conn. Gen. Stat. §15-34(5), includes all power-driven heavier than air

fixed-wing aircraft and rotorcraft.)

Blanket Certificate

I am purchasing ______ gallons of fuel from _________________________.

Name of Distributor

I am the owner or operator of the aircraft or aircraft engine for which this fuel is being purchased.

The aircraft or aircraft engine is: (include the make, model, year, and registration number):

The fuel is being delivered, upon sale, to a tank in which fuel is kept exclusively for aviation

purposes.

The owner of the aircraft is:

an individual

a corporation

another entity.

If the owner of the aircraft is a corporation or another entity, please enter the legal name of the

corporation or entity: ________________________________.

Declaration: I declare under penalty of law that I have examined this declaration (including any

accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete,

and correct. I understand that the penalty for willfully delivering a false declaration to DRS is a fine of

not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid

preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Signature: ____________________________ Print Name: ________________________________

(Signature of Aircraft Owner/Operator)

Title: _________________________________ Date: _____________________________________

Provide this declaration to the distributor and retain a copy for your records.

Form Au-477 - Aircraft Owner Or Operator Declaration Motor Vehicle Fuels Tax Exemption Form - State Of Connecticut - Department Of Revenue Services