Free Utah Application For Government Motor Fuel Tax Refund, TC-114M - Utah

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Utah State Tax Commission

Application For Government Motor Fuel Tax Refund

MG-RF
TC -114M Rev. 7/04

Telephone: (801) 297-2200 for assistance (1-800-662-4335 outside Salt Lake City but inside Utah)
Name Federal identification number

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 quarterly basis.
Invoice number Transaction date Vendor's name and address Number of GALLONS Motor fuel tax paid

1. Total gallons (add "Number of Gallons" column) 2. Total Motor Fuel Tax Paid (add "Motor fuel tax paid" column). This is your TOTAL REFUND

1 2

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.
Print name of person signing this form Signed X Date signed Title Telephone number

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.

General Information
Utah Code Section 59-13-201(7) allows federal and Utah state and local government entities to file for a refund of Utah motor fuel tax paid on motor fuel purchases. For purposes of this law, motor fuels are defined as gasolines. Refund claims for Motor Fuel taxes paid may be filed after the end of any calendar quarter, for taxes accumulated for that calendar quarter. Government entities that are members of (participate in) the State Fuel Network (Network) and use gascards through Fleet Services may not request a fuel tax refund directly from the Tax Commission. Fleet Services will handle all fuel tax refunds for members of the Network, including purchases made outside of the Network. Refund claims or an agreement to extend must be filed within 3 years from the date of over payment. See Utah Code 59-13-210(7). If you need additional help or information, contact the Utah State Tax Commission at (801) 297-2200 or, if outside the Salt Lake area but within Utah, call 1-800-662-4335. Original records supporting the refund claim must be maintained by the government entity for three years following the year of refund. To file for a refund, mail or bring this refund form to the Utah State Tax Commission, 210 North 1950 West, Salt Lake City, Utah 84134.

Instructions For Completing This Form
Enter the full name, address (where refund or correspondence is to be sent) and Federal Identification Number of the government entity applying for the refund in the space provided. Use this same name and number whenever you file for a refund. You must provide all information requested on this form for each purchase of motor fuel for which you paid Utah motor fuel taxes. Attach additional forms if necessary. Do not include tax-exempt fuel purchases (no fuel tax shown on invoice). Filing period is a calendar quarter that begins with the first day of the calendar quarter and ends with the last day of the calendar quarter. Calendar quarters are January_March, April_June, July_September and October_December. You may include multiple calendar quarters, but you must begin and end with complete calendar quarters. Example: April_September 2004 covers two complete calendar quarters. Do not submit claims for incomplete or combination of incomplete calendar quarters, such as May_August.