Form Reg-5mf - Application For Motor Vehicle Fuels Tax Or Petroleum Products Gross Earnings Tax - Connecticut Department Of Revenue Services Page 2
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1
2DECLARATION
HEATING OIL ONLY DISTRIBUTOR
Name of Applicant
Title (Owner, Partner, Corporate Officer or LLC Member).
Business Address
I declare under penalty of false statement that to the best of my knowledge and belief, all fuel sold by the applicant is used exclusively for heating
purposes. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars, or both.)
APPLICANT:
(Print your name)
(Signature)
(Title)
REG-5MF
General Instructions
1.
Print clearly in ink or type all information requested.
2.
Check all applicable boxes.
3.
If you are selling fuel exclusively for heating purposes, you must complete both the front and back
of REG-5MF.
4.
If the space provided is insufficient, attach additional sheets and identify the line number(s) for
which the information is being provided.
REG-5MF Back (Rev. 06/00)
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