Clear form
Utah State Tax Commission
TC-889
Mineral Production Withholding Tax Exemption Certificate
Rev. 4/04
Important: Please read instructions on the back first
If you are an entity claiming exemption under Utah Code 59-6-102(2),
complete Part 1 only
.
If you are claiming a pass-through entity exemption, do not complete Part 1 -
complete Part 2 only
.
Part 1: Exempt Entity Information
Do not complete Part 2
Give a copy of this form to the producer and retain a copy for your records.
Name of entity claiming exemption
Federal EIN
Address
Telephone number
City
State
Zip code
Under penalty of perjury, I certify the above entity is exempt from mineral production withholding tax under Utah Code Section 59-6-102(2).
Print name of authorized officer
Title
Signature of authorized officer
Date signed
X
Part 2: Pass-Through Entity Information
Do not complete Part 1
Send the original of this form, along with a schedule showing the well number, well name and state API number to the
Auditing Division, Utah State Tax Commission, 210 N 1950 W, SLC, UT 84134-2300.
The Tax Commission will either approve or deny the exemption and will return a copy of this form to both the company
disbursing funds and the company requesting exemption.
Name of company disbursing funds
Federal EIN
Address
Telephone number
City
Zip code
State
Name of business
Utah mineral withholding number
R
Federal EIN
Address
City
Zip code
Telephone number
State
Under penalty of perjury, I certify I will be making further distributions of payments received from the attached list of Utah wells and I will
withhold five percent (5%) of all payments made to the owners of these wells. I further certify I am registered to remit withholding tax to
the State of Utah under the account entered above.
Print name of authorized officer
Title
Signature of authorized officer
Date signed
X
Tax Commission Use Only
For part 2 only
By
Approved
Denied (reason):