Form Op-219 - Petroleum Products Gross Earning Tax - 1998
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1STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
GROSS EARNINGS PETROLEUM TAX
GROSS EARNINGS - OUT-OF-STATE AFFIDAVIT WITH REFERENCE TO THE SALES OF
PETROLEUM PRODUCTS SOLD EXCLUSIVELY FOR SALE OR USE IN ANOTHER STATE
In accordance with the provisions of Gross Earnings Tax on Petroleum Products,
the undersigned distributor certifies that the petroleum products purchased from
(Name and Address of Distributor)
will be resold exclusively out of state.
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 affidavit will be effective for one year. If I should desire to purchase petroleum products during
the period the affidavit is in effect and sell within Connecticut, I shall notify the Commissioner of
Revenue Services and my supplier that any privileges granted to me by this affidavit shall become null
and void, and thereafter all future purchases would be subject to 5% Gross Earnings Tax.
Any violation of this affidavit by either supplier 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.
Date _____________________
_________________________________________________________________________
(Trade Name)
_________________________________________________________________________
(Signature of Distributor)
Subscribed and sworn to before me this _____________ day of _________________________ , _____________ .
State of _________________________________ )
SS
County of _______________________________ )
______________________________________________________________________
(Notary Public)
Take this deduction on Line 5 of OP-161, Petroleum Products Gross Earnings Tax Return and enclose a copy of this form when filing
your tax return.
OP-219
(Rev. 11/98)
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