Form Tc-116 - Utah Application For Fuel Tax Refund Page 3
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3Utah Refund Application General Schedule
TC-116A Rev. 9/10
11603
Company name
FEIN/SSN
Schedule type
Product type
Month/Year
From
To
Schedule type
Product type
- Utah tax-paid gallons purchased by government entities
1H
- Gallons of aviation fuel collected at 2.5 cent tax rate
1A
065
- Motor fuel
228
- Diesel fuel (dyed)
1B
- Utah tax-paid gallons exported from Utah
1I
- Gallons of aviation fuel collected at 4 cent tax rate
260
- Repackaged lube oil
130
- Aviation fuel
1C
- Utah tax-paid gallons purchased by Ute Indian Tribe
1J
- Gallons of aviation fuel collected at 9 cent tax rate
160
- Diesel fuel (undyed)
1D
- Utah tax-paid gallons purchased by non-profit agricultural entities
2A
- Utah Environmental Assurance Fee paid gallons exported from Utah
224
- Compressed natural gas
1E
- Eligible gallons of fuel lost or destroyed by fire, flood, crime or accident
2B
- Utah Environmental Assurance Fee paid gallons placed in nonparticipating tanks
1F
- Eligible gallons for each single transaction discharged by bankruptcy
2C
- Utah Environmental Assurance Fee for repackaged
1G
- Gallons returned to refinery for re-refining
3A
- Gallons of fuel delivered to Utah portion of Navajo Nation
4
5
6
7
8
9
1
2
3
Facility/Terminal number
Tax-paid
Purchase date
Invoice
Manifest
Airport code
Supplier’s
(mmddyyyy)
name
gallons
number
number
(only for Sch. type 2A, 2B, 2C)
(for prod. type 130)
Origin
Destination
Total
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