Business Name: Address 1:
ID Type: ID Number: Address 2:
Contact/Return Info
Period Begin: City:
Period End: State: Address Type:
Contact E-mail: Zip Code: Address Change:
Contact Phone: Foreign Country:
Prepared By:
Utah State Tax Commission FTX
TC-116
V 201112219.1 Fuels Tax Refund Application Rev. 12/11
FAILED Edit/Calculate 12/19/2011 11:31:55 AM
A. Motor Fuel B. Undyed C. Aviation Fuel D. Comp.
EXCISE TAX Diesel Natural Gas
1. Utah tax-paid gallons purchased by government entities - - - -
2. Utah tax-paid gallons exported from Utah -
3. Utah tax-paid gallons purchased by Ute Indian Tribe - - -
4. Utah tax-paid gallons purchased by non-profit agricultural entities - - -
5. Total eligible gallons of fuel lost or destroyed - - - -
6. Total eligible gallons for each single transaction of 4,500 or more discharged in bankruptcy - - - -
7. Gallons returned to refinery for re-refining - - -
Schedule 1
8. Total tax-paid gallons - - - -
9. Gallons of aviation fuel subject to minimum tax -
10. Tax per gallon of aviation fuel at 2.5 cents -
11. Gallons of aviation fuel subject to additional tax -
12. Tax per gallon of aviation fuel at 4 cents -
13. Gallons of aviation fuel subject to additional tax -
14. Tax per gallon of aviation fuel at 9 cents -
15. Tax rates 0.245 0.245 0.085
16. Calculated tax-paid - - - -
17. Total Utah excise tax -
UTAH ENVIRONMENTAL ASSURANCE FEE
18. Utah Environmental Assurance Fee paid gallons exported from Utah -
Schedule 2
19. Utah Environmental Assurance Fee paid gallons place in non-participating tanks -
20. Utah Environmental Assurance Fee paid gallons for repackaged oil -
21. Total Utah Environmental Assurance Fee paid gallons -
22. Tax Rate 0.005
23. Calculated Environmental Assurance Fee -
A. Motor Fuel B. Undyed
NAVAJO NATION REFUND Diesel
24. Total taxable gallons reported to the Navajo Nation
25. Gallons delivered to non-Utah portion of Navajo Nation
Schedule 3
26. Total gallons subject to Utah fuel tax (subtract line 25 from line 24) - -
27. Navajo 0.5% credit, if taken on Navajo Distributor Tax Return (multiply line 26 by .005) - -
28. Net taxable gallons available for Utah fuel refund (subtract line 27 from line 26) - -
29. Tax rate 0.18 0.245
30. Navajo Nation fuel tax refund (multiply line 28 by line 29) - -
31. Total Navajo Nation (add line 30, columns A and B) -
32. Total refund (add lines 17, 23 and 31) -
TC-116A - Utah Refund Application General Schedule
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Schedule Product Purchase Invoice Manifest Point of Origin Point of Destination Facility Airport Supplier's Tax Paid
Type Type Date Number Number State State Number Code Name Gallons
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ERROR LISTING
Sheet Row Column
TC116 3 4
TC116 3 6
TC116 2 4
TC116 6 4
TC116 8 4
TC116 7 4
TC116 2 9
TC116 4 9
TC116 5 11
TC116 6 9
TC116 6 11
TC116 5 9
TC116 7 9
TC116 4 4
TC116 5 4
TC116A 12 1
R LISTING
Error
The ID Type is required
The ID is required
The Business Name is required
The Contact E-mail is required
The Prepared By is required
The Contact Phone is required
The Address 1 is required
The City is required
The Address Type is required
The Zip Code is required
The Address Change is required
The State or Foreign Country is required
The Foreign Country or State is required
The Filing Period Begin Date is required
The Filing Period End Date is required
INVALID Schedule/Product Combination: Schedule Type: , Product Type:
Template Instructions
General
Use this spreadsheet to request a refund of taxes or fees you paid. You must complete the entire
application and keep all backup documentation.
You must use this spreadsheet if you:
• Your schedule detail is more than 50 lines
• You file more than one refund request annually
— Check the date to be sure you have the newest version.
— Save the template to your computer before using.
— Save the template as an .xls file before uploading.
Complete all schedules before completing the return.
Enter amounts in the blue boxes. White boxes are populated for you. Yellow boxes are calculated for
you.
Main Return
You must fill out Contact/Return information to complete your return.
Schedule
Start entering your data on line 12. Do not leave blank lines in the schedule. Data entered below a
blank line will not import.
Line-by-Line Instructions
Click here for line-by-line return and schedule instructions.
Click here to see the Airport Code List
Click here to upload your file.
28-Oct