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Utah State Tax Commission
NV-RF
Application for Navajo Nation TC-126
Fuel Tax Refund Rev. 8/02
Name Federal ID number
Street address Filing period (Begin: mmyy End: mmyy)
End: _______
Begin: _______
City, State, Zip code
General Information
You must first complete the Navajo Tax Commission Monthly Fuel Distributor Tax Return, form 900, to prepare this
refund application.
You must attach a completed copy of Navajo form 900, including all schedules and fuel manifests, to this refund application.
A refund application may be filed on a monthly basis and should be filed on or before the 30th day following the refund period.
You must retain original records supporting this refund application for three years following the year of the refund.
Mail or bring the refund application, with all required attachments to the Utah State Tax Commission, 210 North
1950 West, Salt Lake City, Utah 84134-0511.
For assistance: Web Site: www.tax.utah.gov
Phone: 801-297-2200
Toll Free: 800-662-4335
1. Total Navajo Nation taxable gallons (from line 3, form 900, Navajo Distributor Tax Return)
2. Gallons delivered to non-Utah portion of Navajo Nation (if included on line 3, form 900, Navajo Distributor Tax Return)
3. Total gallons delivered to Utah portion of Navajo Nation (subtract line 2 from line 1)
4. Dyed diesel fuel gallons included on line 3
5. Total gallons subject to Utah fuel tax (subtract line 4 from line 3)
6. Navajo 0.5% credit, if taken on line 4, form 900, Navajo Distributor Tax Return (multiply line 5 by .005)
7. NET taxable gallons available for Utah fuel tax refund (subtract line 6 from line 5)
8. REFUND (multiply line 7 by .18) $
I certify that I meet all the conditions to qualify for this refund. I have examined this refund application, including
any accompanying schedules, and certify that to the best of my knowledge it is true, correct and complete.
Date signed
Signature Title Telephone number
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If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811
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(TDD (801) 297-3819). Please allow three working days for a response.