Free TC-111 - Utah

Petroleum Products Carrier Report - Schedule of Deliveries 2A
Company name and address FEIN

Utah State Tax Commission
Terminal code Month/Year

Product type (check one)

65 Gasoline 124 Gasohol 125 Aviation gasoline
Person hiring the carrier (1) (2) Company name FEIN

130 Jet Fuel 72 Dyed Kerosene 142 Undyed Kerosene
Seller (3) Company name (4) FEIN (5) Mode (6) Origin (7) Name

160 Undyed Diesel Fuel 228 Dyed Fuel Diesel Specify ____________________
Delivery destination (8) Address

This report must be filed monthly, even if no shipments were made. This report is due on the last day of the following month. See additional instructions on back.

Gallons (9) FEIN (10) Date delivered (11) Document number (12) Gross (13) Net

I certify to the best of my knowledge that this form is complete and true. Signature Title Telephone number Date

TOTAL GALLONS

IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.

Clear form

TC-111 Rev. Print Form 8/99

General Instructions This schedule provides detail of each delivery. Total all deliveries of fuel from out-of-state locations to locations inside of Utah. Columns (1) and (2) Column (3) &(4) Column (5) Person hiring the carrier - Enter the name and FEIN of the company that hired the carrier. Seller - Enter the name of the company from whose account the fuel was withdrawn at the terminal. Mode of transportation - Enter one of the following options: J = Truck R = Rail B = Barge GS - Gas station PL = Pipeline S = Ship (Great lakes or ocean marine vessel) Origin - Enter the city and/or state or country shown on the delivery document (bill of lading, manifest, or other loading document issued by the terminal operator) where the petroleum product was loaded for each delivery. If the product was loaded at a terminal, enter the IRS Terminal Control Code assigned to that terminal. Delivery destination - Enter the name, address, and FEIN of the final delivery point. If delivered to a terminal, enter the IRS Terminal Control Code for that terminal. Date delivered - Enter the date the petroleum products was delivered for each delivery (Month/Day/Year). Document number - Enter the identifying number from the document issued at the terminal when product is removed over the rack. In the case of pipeline or barge movements, enter the pipeline or barge ticket number. Gallons - Enter the number of gross and net gallons delivered for each delivery.

Column (6)

Column (7), (8) & (9)

Column (10) Column (11)

Column (12) & (13)

Mail this report to the Utah State Tax Commission, Auditing Division, 210 North 1950 West, Salt Lake City, UT 84134. Telephone number is (801) 297-2200.