Free TC-119 - Utah

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Utah State Tax Commission

Application For Refund of Aviation Fuel Purchased at the Salt Lake International Airport

AVF-RF
TC -119 Rev. 11/01

Telephone: 801-297-2200 for assistance (800-662-4335 outside Salt Lake City but inside Utah)
Name of federally certificated air carrier Federal identification or Social Security no.

Street address

Filing period (Begin: mmyy End: mmyy) Begin: End:

City, State, ZIP code

Refund application may not be filed more often than on a monthly basis. A carrier must file a claim for a refund within 90 days of the end of the tax year for which a claim is made.

PART A: Conditions and Limitations of Aviation Fuel Tax Refund I certify that the following conditions and limitations have been met and that I qualify for a refund of Aviation Fuel tax paid for aviation fuel purchased at the Salt Lake International Airport. I am a federally certificated air carrier holding a certificate issued by the Federal Aviation Administration authorized to conduct an all-cargo operation or scheduled operation, as defined in 14 C.F.R. Section 119.3. I am entitled to a 1.5 cent refund of the aviation fuel tax paid on gallons of aviation fuel purchased at the Salt Lake International Airport. I have attached a completed Schedule A to support this Aviation Fuel refund claim. I understand the Tax Commission may reject unsubstantiated claims and may require additional evidence or information. If I make any false claim, report, or statement, with intent to defraud or secure a refund to which I am not entitled, I will be subject to criminal penalties provided under Section 59-1-401. In addition to these penalties, I may not receive any refund as a claimant for a period of five years. Mail or bring the refund application, with all required attachments to the Utah State Tax Commission, 210 North 1950 West, Salt Lake City, Utah 84134-0512. For assistance: E-mail: [email protected] Web Site: www.tax.ex.state.ut.us Phone: 801-297-2200 Toll Free: 800-662-4335 PART B: Qualifying Gallons/Total Refund Due 1. Total gallons purchased at the Salt Lake International Airport qualifying for refund. (Enter your gallons purchased from Schedule A, line 17) 2. Tax refund rate 3. TOTAL REFUND (multiply line 1 by line 2) 1 2 3

0.015

I certify that I meet all the conditions to qualify for this refund. I have examined this refund application, including any accompanying schedules, and certify that to the best of my knowledge it is true, correct and complete.
Signed X Date signed Title Telephone

If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 (TDD (801) 297-3819). Please allow three working days for a response.

Schedule A Record of Gallons Purchased at Salt Lake International Airport
Name of federally certificated air carrier

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TC -119A Rev. 11/01

Federal identification or social security number

Vendor name and address (include FEIN if known)

Transaction date

Invoice number

Bill of lading number

Airport name

Number of gallons purchased

Utah aviation fuel tax paid

1.

Salt Lake International

2.

Salt Lake International

3.

Salt Lake International

4.

Salt Lake International

5.

Salt Lake International

6.

Salt Lake International

7.

Salt Lake International

8.

Salt Lake International

9.

Salt Lake International

10.

Salt Lake International

11.

Salt Lake International

12.

Salt Lake International

13.

Salt Lake International

14.

Salt Lake International

15.

Salt Lake International

16.

Salt Lake International

17. Add the gallons in the "Number of gallons purchased" column from lines 1 though 16. Enter this on form TC-119, line 1. Attach additional schedules if needed.