Free TC-113 - Utah

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Utah State Tax Commission

ES-RF
TC -113
Rev. 6/03

Application For Environmental Assurance Fee Refund

Telephone: (801) 297-2200 for assistance (1-800-662-4335 outside Salt Lake City but inside Utah)
Name Federal identification or Social Security no.

Mailing 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.
The following conditions are required to file for an Environmental Assurance Fee refund.

1. I was the consumer, retailer and/or exporter of the petroleum products claimed; 2. For a consumer and/or retailer: I owned or leased the stationary storage tank where the gallons claimed were stored; 3. None of the storage tanks where the claimed gallons are stored are covered by the Department of Environmental Quality's Environmental Assurance Program; and 4. The Environmental Assurance Fee was paid to my supplier on all gallons claimed. Purchase invoices and tank throughput records (i.e. inventory records, meter readings, etc.) should be available for audit for three years from the date of the refund.
Mail to: Utah State Tax Commission 210 N 1950 W Salt Lake City, UT 84134

Refund Rate Table (Use for line 2 below)
Rate for filing Rate for filing periods ending prior periods beginning to or on 6/30/03 on 7/1/03 or later 0.0025 Environmental Assurance 0.0050 or 0.25% Fee Refund Rate or 0.50%

1. Total gallons qualifying for refund (from schedule on back) 2. Enter refund rate (see Refund Rate Table above for the correct rate for filing period) 3. Multiply line 1 by line 2. This is your TOTAL REFUND

1 2 3

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) 297-2020). Please allow three working days for a response.

Environmental Assurance Fee Refund Schedule
Tank type Tank location Facility number Invoice date Invoice number Supplier Product type

TC-113A Schedule

Number of gallons

Total Gallons