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Utah State Tax Commission

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Proof of Exportation For Motor Fuel, Undyed Diesel or Other Petroleum Products
Use this form when exporting motor fuel and undyed diesel as defined in Utah Code 59-13-102 and/or petroleum as defined in Utah Code 19-6-402 (19). Complete all information. Retain this form for your records.
Purchaser (consignee) Address City Seller's invoice number State ZIP code Fuel or product type Seller Address City State Buyer's fuel license numbers for destination state

TC-112 Rev. 7/00

ZIP code

Invoice date

Date of exportation

Bill-of-lading number

Destination (city and state)

Gallons

I certify, under penalty of law, that the above information is true and correct and that the motor fuel or undyed diesel and other petroleum products will be for sale or use in the state of destination. Purchaser (consignee) signature X Date signed Seller's signature X

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Date signed

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