Tourism Surcharge Return
on the Rental/Leasing
of Passenger Motor Vehicles
Department of Revenue Services
State of Connecticut
PO Box 2997
Hartford CT 06104-2997
If the address
at right is
Declaration: I declare under penalty of law that I have examined this return (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 fine of not more than $5,000, or imprisonment for not more than five 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.
Check here if this is an amended return.
If you have ceased leasing operations,
enter date you ceased operations:
New address or trade name:
Enter new mailing address:
Enter new trade name:
Enter new physical location (Not PO box):
For Period Ending
Connecticut Tax Registration Number
Federal Employer Identification Number
For DRS Use Only
You must complete this return in blue or black ink only.
Make your check payable to: Commissioner of Revenue
Services. Include your Connecticut tax registration number on
your check. The Department of Revenue Services (DRS) may
submit your check to your bank electronically.
You must file a return even if no surcharge is due. Enter “0” on
Line 1 and Line 2 and sign the return.
Rounding: You must round off cents to the nearest whole dollar
on your returns and schedules.
Due Date: The due date of the return is the last day of the month
after the end of the period indicated above.
New Owners: Do not use the previous owner’s form to file your
return. Any change in ownership requires a new Connecticut tax
Signature: You must sign the return.
If you have questions, call Taxpayer Services at 1-800-382-9463