Form Op-219 - Petroleum Products Gross Earnings Tax printable pdf download

Form Op-219 - Petroleum Products Gross Earnings Tax

Department of Revenue Services

Form OP-219

State of Connecticut

25 Sigourney St Ste 2

Petroleum Products Gross Earnings Tax

Hartford CT 06106-5032

(Rev. 10/10)

Gross Earnings - Out-of-State Declaration With Reference to the Sales of Petroleum Products

Sold Exclusively for Sale or Use in Another State

In accordance with the provisions of the petroleum products gross earnings tax,

the undersigned distributor certifies that the petroleum products purchased from:

Name of distributor: See note below.

Address

City or town

State

ZIP code

will be resold exclusively outside of the State of Connecticut.

The following information is furnished:

(a)

I intend to purchase petroleum products for exclusive sales or use in the following state:

State of: ______________________________________________________________________________________

(b)

This declaration will be effective for one year. If I should desire to purchase petroleum products during the period the

declaration is in effect and sell within Connecticut, I will notify the Commissioner of Revenue Services and my distributor

that any privileges granted to me by this declaration are null and void and, thereafter, all future purchases are subject to

7% petroleum products gross earnings tax.

Any violation of this declaration by either the distributor or purchaser will subject all transactions to the full extent of the tax, penalty,

interest, and civil penalties for false statement as provided by law.

Name and address of distributor purchasing petroleum products for sale or use in another state

Signature of distributor

Date

Note to distributor who made the first sale in Connecticut of the petroleum products referenced 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 16 of the return.

Form Op-219 - Petroleum Products Gross Earnings Tax