EX-RF
TC-943 Rev. 1/01
Name
Federal ID (FEIN/EIN)
Telephone: (801) 297-2200 for assistance (1-800-662-4335 outside Salt Lake City but inside Utah)
Street address
Filing period (Begin: mmyy End: mmyy) Begin: End:
Application For Exported Tax Paid Diesel Refund
City, State, ZIP code
Utah State Tax Commission
Refund application may not be filed more often than on a monthly basis.
Enter the state exported to (complete separate form for each state) License and account number in destination states
Clear form
Point of origin Terminal # City, State
Destination City,State
Carrier
Customer's name Customer FEIN
Product type
Document number Date shipped Invoice number Bill-of-lading
Gallons
Tax paid
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
TOTAL GALLONS TOTAL REFUND
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 (TDD (801) 297-3819). Please allow three working days for a response.
General Information Utah Code Section 59-13-301 allows for a refund of Utah tax paid on undyed diesel fuel exported from Utah. The exporter may obtain a refund of the special fuel taxes paid by filing form TC-943, Refund For Exports of Tax Paid Diesel, within 180 days of exporting the fuel. If you need additional help or information, contact the Utah State Tax Commission at (801) 297-2200 or if outside the Salt Lake area, call 1-800-662-4335. Original records supporting the refund claim must be maintained by the exporter for three years following the year of refund. Copies of the supplier invoice, shipping document, and customer invoice must be submitted with this request. 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, physical and mailing address, Federal Identification or Social Security Number of the exporter applying for the refund in the space provided. Use this name and number whenever you file for a refund. Enter the month and year of the refund period and your telephone number. You must provide all information requested for each export for which you are claiming a refund. Complete a separate form for each state Utah tax paid undyed diesel fuel is exported to for the refund period. Attach additional forms if necessary. Include the license or account number for each destination state.