Form Tc-889 - Mineral Production Withholding Tax Exemption Certificate
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Mineral Production Withholding
Give a copy of this form to the producer
Tax Exemption Certificate
and retain a copy for your records.
If you are a tax exempt entity claiming this exemption,
complete Part 1, Part 2 and Part 5 only
.
If you are claiming a pass-through entity exemption,
complete Part 1, Part 3 and Part 5 only
.
If you are claiming the special exemption, complete Part 1, Part 4 and Part 5 only.
Part 1: Name of Producer
Name of company disbursing funds
Utah mineral withholding number
Address
Federal EIN
City
State
Zip code
Telephone number
Part 2: Tax Exempt Entity Information
Name of entity claiming exemption
Federal EIN
Address
Telephone number
City
State
Zip code
Part 3: Pass-Through Entity Information
Name of business
Utah mineral withholding number
Address
Federal EIN
City
State
Zip code
Telephone number
Tax Commission Use Only
By
Approved
Denied (reason):
Part 4: Special Exemption
Name of entity claiming exemption
Federal EIN
Address
Telephone number
City
State
Zip code
Part 5: Authorized Signature
Under penalty of perjury, I certify the above entity is exempt from mineral withholding tax under Utah Code §59-6-102.
Print name of authorized officer
Title
Signature of authorized officer
Date signed
Send completed original form, along with the schedule required for Part 3 (if applicable) to,
TC-889 Rev. 7/08
Auditing Division
Utah State Tax Commission
210 North 1950 West
Salt Lake City, Utah 84134-2300
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