Form Tc-125 - Application For Loss Or Destruction Of Fuel Refund
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Fuel
Utah State Tax Commission
Application For Loss or
TC -125
Rev. 7/08
Destruction of Fuel 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.
Street address
Date of incident (mmddyy)
City, State, ZIP code
Time of incident Location of incident
Name of investigating officer and agencies at the scene
Information on any insurance coverage related to the incident (insurance company name, policy number, agent, telephone no., etc.)
Give brief explanation of the cause of the incident
Gallons
Tax paid
1. TOTAL eligible gallons (8,000 or more) of
motor fuel
lost or destroyed due to fire, flood,
crime, or accident
2. TOTAL eligible gallons (8,000 or more) of
aviation fuel
lost or destroyed due to fire, flood,
crime, or accident
3. TOTAL eligible gallons (7,000 or more) of
undyed diesel
fuel lost or destroyed due to fire,
flood, crime, or accident
4. TOTAL of all eligible gallons of fuels lost or destroyed due to fire, flood, crime, or
accident (add lines 1, 2, and 3)
$
5. Total tax paid on gallons (not reimbursed or covered by insurance) This is your TOTAL REFUND
Affidavit of Claimant
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
Date signed
Title
Telephone
X
STATE OF UTAH
SS
COUNTY OF _________________________________
On this ______ day of _________________, in the year 20_______, before me personally appeared __________________________________
to me known and known to me to be the person, and described in, and who executed the foregoing instrument, and acknowledged to me that he
executed the same.
(NOTARY SEAL)
Notary Public
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.
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Parent category: Financial