Clear form
Utah State Tax Commission
Print Form
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
Print Form
Date signed
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form