Form Cert-116 - Exempt Petroleum Products Certificate (Page 2 of 2) in pdf

Name of Purchaser:

Address:

Federal Employer Identiﬁ cation Number

Connecticut Tax Registration Number

(If none, explain)

Name of Distributor:

Address:

Federal Employer Identiﬁ cation Number

Connecticut Tax Registration Number

(If none, explain)





 Certiﬁ cate for One Purchase Only

Check One Box:

Blanket Certiﬁ cate

Description of Petroleum Product(s) Sold:



The product designated by the American Society for Testing and Materials as “Speciﬁ cation for Heating Oil D396-69,” commonly

known as Number 2 heating oil, to be used exclusively for heating purposes or to be used in a commercial ﬁ shing vessel, which vessel

qualiﬁ es for an exemption under Conn. Gen. Stat. §12-412;



Kerosene, commonly known as Number 1 oil, to be used exclusively for heating purposes, provided delivery is of both Number 1 and

Number 2 oil and via a truck with a metered delivery ticket to a residential dwelling or to a centrally metered system serving a group

of residential dwellings;



The product identiﬁ ed as propane gas to be used exclusively for heating purposes or to be used as a fuel for a school bus;



Bunker fuel oil, intermediate fuel, marine diesel oil, and marine gas oil to be used in any vessel having a displacement exceeding

4,000 dead weight tons;



Any ﬁ rst sale occurring on or after July 1, 2002, of Number 6 fuel oil, as deﬁ ned in regulations adopted according to Conn. Gen.

Stat. §16a-22c, to be used exclusively by a company which, in accordance with census data contained in the Standard Industrial

Classiﬁ cation (SIC) Manual, 1987, is included in code classiﬁ cations 2000 to 3999, inclusive, or in Sector 31, 32, or 33 in the

North American Industry Classiﬁ cation Systems (NAICS) United States, 1997;



Any ﬁ rst sale occurring on or after July 1, 2002, of Number 2 heating oil to be used exclusively in a vessel primarily engaged in

interstate commerce, which vessel qualiﬁ es for an exemption under Conn. Gen. Stat. §12-412;



Parafﬁ n or microcrystalline waxes;

 Any ﬁ rst sale occurring on or after July 1, 2006, of a commercial heating oil blend containing not less than 10% alternative fuels derived

from agricultural produce, food waste, waste vegetable oil or municipal solid waste including but not limited to biodiesel or low sulfur

dyed diesel fuel. Commercial heating oil includes Number 2 heating oil, Number 4 fuel oil, Number 6 fuel oil, low sulfur dyed diesel

fuel and kerosene. Such blended products must be used for commercial heating;

 Any ﬁ rst sale occurring on or after July 1, 2007, within Connecticut of diesel fuel, other than diesel fuel to be used in an electric

generating facility to generate electricity; or

 Any ﬁ rst sale occuring on or after July 1, 2013, within Connecticut of cosmetic mineral oil.

Declaration by Purchaser

The petroleum product(s) described above is an exempt petroleum product as deﬁ ned in this certiﬁ cate and charges for the product(s)

are not subject to the petroleum products gross earnings tax.

I declare under penalty of law that I have examined this certiﬁ cate (including any accompanying schedules and statements) 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 to DRS is

a ﬁ ne of not more than $5,000, or imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the

taxpayer is based on all information of which the preparer has any knowledge.

Name of Purchaser

By:

Signature of Authorized Owner, Ofﬁ cer, or Agent

Title

Date

CERT-116 (Rev. 06/13)

Form Cert-116 - Exempt Petroleum Products Certificate Page 2

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