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Form Au-477 - Aircraft Owner/operator Declaration - Connecticut Department Of Revenue Services

STATE OF CONNECTICUT

DEPARTMENT OF REVENUE SERVICES

25 SIGOURNEY STREET

FORM AU-477

HARTFORD CT 06106-5032

AIRCRAFT OWNER/OPERATOR DECLARATION

(Rev. 07/00)

Motor Vehicle Fuels Tax Exemption

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):

Such 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.

The legal name of the owner is ______________________________. My relationship

to the owner is ________________________________ (self, officer, partner, operator

of aircraft, etc.)

___________________________________

Signature of Aircraft Owner/Operator

I declare under the penalty of false statement that I have examined this declaration, FORM

AU-477, and, to the best of my knowledge and belief, it is true, complete, and correct. (The

penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two

thousand dollars, or both.)

Signature: ____________________________ Print Name: ______________________

Title: ________________________________ Date: ___________________________

PROVIDE THE ORIGINAL OF THIS DECLARATION TO THE DISTRIBUTOR AND RETAIN A COPY FOR YOUR RECORDS

Form Au-477 - Aircraft Owner/operator Declaration - Connecticut Department Of Revenue Services