DR 1501 (06/28/16)
COLORADO DEPARTMENT OF REVENUE
P.O. Box 17087
Denver CO 80217-0087

                                                    Affidavit

                    Retail Sales of Liquefied Petroleum Gas (Propane)

                                                    Instructions

Who must submit this form?  Any person, entity, or group   Additional information regarding who is required to be 
of persons or entities acting as a unit who sell liquefied licensed as a fuel distributor or who is required to file this 
petroleum gas (propane) only at the retail level of trade, affidavit may be obtained by contacting the Department of 
who does not desire to be licensed as a fuel distributor,  Revenue’s Fuel Tax Unit at 303-205-8205.
pursuant to C.R.S. 39-27-104.  
                                                           Upon receipt and processing, the Department of Revenue’s 
Such company must conspicuously post at the distribution   Fuel Tax Unit will issue a letter confirming receipt and 
point a sign indicating the liquefied petroleum gas        approval of the affidavit.
(propane) is not for sale for use in motor vehicles.

Mail completed form to:
               Colorado Department of Revenue
 Fuel Tax Unit, Rm 200 
               P.O. Box 17087 
               Denver CO 80217-0087 

DR 1501 (06/28/16)
COLORADO DEPARTMENT OF REVENUE
P.O. Box 17087
Denver CO 80217-0087

                                                  Affidavit

                    Retail Sales of Liquefied Petroleum Gas (Propane)

Taxpayer Last Name (owner, partners, or other business organization)           First Name              Middle Initial

Trade Name/Doing Business As (if applicable – corporations, limited partnerships, and limited liability companies using their true name do not register for trade name)

Address of Principal Place of Business                               City                     State ZIP

County                                                               City Limits in which business is located (if applicable) Telephone

Mailing Address (if different from above)                            City                     State ZIP

County                                                               Telephone                FEIN (if unavailable, SSN)

Email Address

I, _______________________________________________, a seller of liquefied petroleum gas (propane) at the 
retail level of trade, swear or affirm under penalty of perjury under the laws of the State of Colorado; all of the following 
statements are true:

   I do not act as a distributor of liquefied petroleum gas (propane) as defined by section 39-27-101 (7) of the 
 Colorado Revised Statutes.

   I sell liquefied petroleum gas (propane) only at the retail level of trade.

   I do not sell liquefied petroleum gas (propane) that is used as special fuel.

   I will not place liquefied petroleum gas (propane) in the fuel tank of a motor vehicle as part of any sale; if I do place 
   the liquefied petroleum gas (propane) in the fuel tank of a motor vehicle, I will be subject to the penalties set forth in 
 section 39-27-104 of the Colorado Revised Statutes.

   I do not use liquefied petroleum gas (propane) from a cargo tank to propel a cargo tank motor vehicle on the 
 highways in Colorado.

   I will conspicuously post at the distribution point a sign indicating that the liquefied petroleum gas (propane) is not for 
 sale for use in motor vehicles.

   I will obtain a fuel distributor license from the Colorado Department of Revenue before I begin sales of liquefied 
 petroleum gas (propane) used in the fuel tank of a motor vehicle.

   I understand that this sworn statement is required by law because I am a retail supplier of liquefied petroleum gas 
 (propane). I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this 
 sworn affidavit is punishable under the criminal laws of the State of Colorado as perjury in the second degree under 
 Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is 
 fraudulently received.

Type or Print Authorized Signature                                             Title

Signature of Owner, Partner, or Corporate Officer                              Date (MM/DD/YY)