Form Op-218 - Petroleum Products Gross Earnings Tax
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1Department of Revenue Services
Form OP-218
State of Connecticut
25 Sigourney St Ste 2
Petroleum Products Gross Earnings Tax
Hartford CT 06106-5032
(Rev. 06/13)
This Certifi cation Applies to Products Purchased in Connecticut But Sold Out of State
Name of exporting company
Address
City or town
State
ZIP code
Purchased from (name of distributor)
Period covered
State shipped to
Exporting Company’s Certifi cation
This certifi es that the exporting company listed above has sold the petroleum products listed below, in the quantities shown, for sale or
use outside the State of Connecticut. These products were purchased in the State of Connecticut and the 8.1% petroleum products gross
earnings tax was paid on the purchase price listed below. Therefore, the exporting company listed above is requesting payment in the
amount of $ ________________________________________ , which represents the gross earnings tax paid on these products.
Type of Petroleum Product(s)
Gallons
Purchase Price
Gross Earnings Tax Paid
$
Total
$
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) or document
and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or
document to the Department of Revenue Services (DRS) is a fi ne of not more than $1,000 or imprisonment for not more than one year, or both.
Signed
Title
Date
Endorsement by Distributor: Do not complete this section if you are the distributor who made the fi rst sale in
Connecticut of the petroleum product(s) listed above. See note below.
To
____________________________________________________________________________________________________________________
(Name of distributor)
This certifi es that the information shown above is correct. A credit in the amount of $
_____________________________________
has been made to
______________________________________________________________________________________________________
(Name of exporting company/distributor)
We request reimbursement of the petroleum products gross earnings tax paid as detailed below:
Purchase price: ..........................................$
__________________________________
Gross earnings tax refund requested: ........$
__________________________________
Name of Distributor
Date
Signed
Title
A distributor making the fi rst sale in Connecticut of the petroleum product(s) listed above must attach a copy of this form to their Form OP-161, Petroleum
Products Gross Earnings Tax Return, to support any deduction claimed.
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