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Utah State Tax Commission
TC-112
Proof of Exportation For Rev. 7/00
Motor Fuel, Undyed Diesel or Other Petroleum Products
Use this form when exporting motor fuel and undyed diesel as defined in Utah Code 59-13-102 and/or petroleum
as defined in Utah Code 19-6-402 (19). Complete all information. Retain this form for your records.
Purchaser (consignee) Seller
Address Address
City State ZIP code City State ZIP code
Fuel or
Seller's Buyer's fuel
Invoice Date of Bill-of-lading Destination
product
invoice license numbers for Gallons
date exportation number (city and state)
type
number destination state
I certify, under penalty of law, that the above information is true and correct and that the motor fuel or undyed diesel and other
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petroleum products will be for sale or use in the state of destination.
Date signed Seller's signature Date signed
Purchaser (consignee) signature
X
X
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