Free TC-129, Application for Fuel Tax Refund on Re-refined Mixed Fuel - Utah

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Utah State Tax Commission

Fuel
TC -129 Rev. 7/08

Application for Fuel Tax Refund on Re-refined Mixed Fuel

Telephone: (801) 297-2200 for assistance (1-800-662-4335 outside Salt Lake City but inside Utah) Get forms online - tax.utah.gov Claimant's name (retailer, wholesaler or licensed fuel tax distributor) Federal identification or Social Security no.

Claimant's mailing address

City, State, ZIP code

Date of incident Time of incident Location of incident Brief explanation of the incident:

Name of refinery fuel returned to

Attachments Required 1. Copies of all original invoices or bills-of-lading for re-refined fuel gallons shown below, and 2. Written verification from refinery certifying: a. Number of gallons returned to refinery for re-refining; and b. Date fuel was returned to refinery for re-refining.
Gallons 1. Motor fuel eligible for refund Tax paid Refund claimed

2. Aviation fuel eligible for refund

3. Special fuel eligible for refund

4. Dyed diesel fuel gallons not eligible for refund 5. Total refund of all eligible fuel tax (add "Refund claimed" column, lines 1, 2 and 3). This is your TOTAL REFUND $

Affidavit of Claimant I certify that I meet all the conditions to qualify for this refund. I have examined this refund application, including all required attachments, and certify that to the best of my knowledge it is true, correct and complete.
Print name of person signing claim Signed X Date signed Name of contact person, if different Title Telephone

STATE OF UTAH SS COUNTY OF _________________________________ On this ______ day of _________________, in the year 20_______, before me personally appeared __________________________________ to me known and known to me to be the person, and described in, and who executed the foregoing instrument, and acknowledged to me that he executed the same. (NOTARY SEAL) Notary Public
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 (TDD (801) 297-2020). Please allow three working days for a response.

Eligibility and General Information 1. Utah law (59-13-202.5) allows retailers, wholesalers or licensed distributors to claim a refund of Utah fuel tax paid on motor fuel if: dyed diesel fuel or special fuel is mixed with motor or aviation fuel; and the mixed motor or aviation fuel is returned to the refinery for re-refining. 2. Utah law (59-13-322) allows retailers, wholesalers, licensed distributors or licensed suppliers to claim a refund of Utah fuel tax paid on special fuel if: dyed diesel fuel is mixed with special fuel; and the mixed special fuel is returned to the refinery for re-refining. 3. You must attach copies of all original invoices or bills of lading showing Utah fuel tax paid for the fuel gallons included in this refund application: For motor or aviation fuel, attach copies of bill(s) of lading. For special fuel, attach copies of original invoice(s). 4. You must attach written verification from a refinery showing: the number of gallons of mixed motor, aviation or special fuel returned to the refinery for re-refinement; the date the mixed motor or special fuel gallons were returned to the refinery; and that Utah motor, aviation or special fuel tax was paid on the mixed fuel returned to be re-refined. 5. You must have your claim notarized. 6. You must file your application for refund or credit with the Tax Commission within 90 days of the date the motor fuel, special fuel or aviation fuel was returned to the refinery for re-refinement. Mailing address: Utah State Tax Commission 210 N 1950 W Salt Lake City UT 84134