Form Tc-111 - Petroleum Products Carrier Report
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1
2Utah State Tax Commission
Petroleum Products Carrier Report - Schedule of Deliveries 2A
Terminal code
Company name and address
FEIN
Month/Year
Product type (check one)
This report must be filed monthly, even
if no shipments were made. This report
65 Gasoline
160 Undyed Diesel Fuel
130 Jet Fuel
is due on the last day of the following
month. See additional instructions on back.
124 Gasohol
228 Dyed Fuel Diesel
72 Dyed Kerosene
125 Aviation gasoline
Specify ____________________
142 Undyed Kerosene
Gallons
Person hiring the carrier
Seller
Delivery destination
(11)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(12)
(13)
Company
Company
Document
Date
number
name
FEIN
name
FEIN
Mode
Origin
Name
Address
FEIN
delivered
Gross
Net
TOTAL
I certify to the best of my knowledge that this form is complete and true.
GALLONS
Signature
Title
Telephone number
Date
TC-111 Rev. 8/99
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Parent category: Financial