Petroleum Products Carrier Report - Schedule Of Deliveries

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Utah State Tax Commission
Petroleum Products Carrier Report - Schedule of Deliveries 2A
FEIN
Terminal code
Company name and address
Month/Year
Product type (check one)
This report must be filed monthly, even
if no shipments were made. This report
65 Gasoline
130 Jet Fuel
160 Undyed Diesel 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
Delivery destination
Seller
(3)
(6)
(11)
(1)
(2)
(4)
(5)
(7)
(8)
(9)
(10)
(12)
(13)
Company
Document
Company
Date
name
Origin
number
name
FEIN
FEIN
Mode
Name
Address
FEIN
delivered
Gross
Net
I certify to the best of my knowledge that this form is complete and true.
TOTAL
GALLONS
Signature
Telephone number
Title
Date
TC-111 Rev. 8/99
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