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UTAH STATE BUSINESS AND TAX REGISTRATION

TC-69

Rev. 6/13

Use form TC-69 to register with the Utah State Tax Commission for the taxes listed below. To register a DBA, use the Business Name Registration / DBA Application, available at all Department of Commerce registration locations, online at commerce.utah.gov, or by phone at 801-530-4849.

General Instructions

•Read the instructions carefully. Type or print clearly. Incomplete or illegible registration forms will be rejected.

•Mail or fax the completed form to the Tax Commission (address and fax number at right).

•Allow us 15 business days to process this form. For faster processing, register online at osbr.utah.gov.

•Contact the proper city or county for business licensing requirements.

Utah State Tax Commission

210 North 1950 West

Salt Lake City, UT 84134-3310

801-297-2200

1-800-662-4335

Fax: 801-297-3573

tax.utah.gov

If you are a sole proprietor applying for the tax license(s) listed below AND you are not a U.S. citizen, you must apply in person at a Tax Commission office and bring proof that you are in the United States lawfully under 8 U.S.C. 1641. Bring your employment authorization card and documentation showing the I-94 (arrival/departure) number and Alien Registration Number issued by the U.S. Citizenship and Immigration Service.

Section 1 – Type of Registration

1a. Check each box that applies		Fee	Complete Sections
	Employer Withholding License	No Fee	2, 3, 14
	Mineral Production Withholding	No Fee	2, 4, 14
 Sales and Use Tax License		No Fee	2, 7, 14

Cable operator or multi-channel video

	or audio service provider	No Fee	2, 7, 14
	Beer Tax (distributor/manufacturer only)	No Fee	2, 13, 14
	Insurance Premium	No Fee	2, 5, 14
	Self-Insured Employer	No Fee	2, 6, 14
	Payroll Service Withholding Submitter	No Fee	2, 14
 Submitter or 3rd Party Preparer		No Fee	2, 14
	Cigarette and Tobacco License	$30 per location	2, 12, 14
	(make check payable to Utah State Tax Commission)
	 Cigarette Stamper	License and Bond†	2, 12, 14
	 Tobacco Products Distributor	License and Bond†	2, 12, 14
Out of State Cigarette/Tobacco PACT Act		No Fee	2, 12, 14
	Delivery Shipper
Natural Gas or Electricity Purchases for		No Fee	2, 7, 14
	Resale or Transportation

USTC Use Only

†You must provide a bond for cigarette stamping and tobacco wholesale distribution (see Section 12 for details).

Get a surety or performance bond from an insurance company. Attach the bond to this form, or forward the bond after submitting the form.

	Fuel Tax License (motor fuel, special fuel,	No Fee	2, 8, 14
	aviation fuel, environmental assurance fee,
	compressed natural gas, liquefied natural gas)
	Mining Severance	No Fee	2, 9, 14
	Oil & Gas Conservation and Severance	No Fee	2, 10, 14
	Radioactive Waste	No Fee	2, 11, 14
1b.	Previous or existing accounts: Enter all previous or existing Utah tax
	account numbers for all owners, officers, members, trustees and partners: ___________________________

____________________________________________________________

If you purchase a business, have the seller provide you with a letter from the Tax Commission stating no sales and use tax is due, or withhold enough of the purchase money to pay all taxes. You will be held personally liable for the seller's unpaid sales and use tax, including all sales-related taxes, if neither of these conditions is met (Utah Code §59-12-112).

Sales, withholding and fuel tax licenses are conditional. If an applicant or a fiduciary (officer, member, owner) has a history of filing or paying late, the applicant must resolve past delinquencies and/or post a bond. Fuel tax bonds may be combined into one bond, and the amount will be the sum of the required amounts for each fuel tax type. There is an exception to the bond requirement for aviation fuel only; the exception exists if the monthly average tax liability is less than $500 and retail sales of aviation fuel are made to both federally certificated air carriers and other persons.

NOTE: Skip this paper form! Use TaxExpress to register your business with the Tax Commission, Dept. of Commerce, Dept. of Workforce Services and select local governments. Go to osbr.utah.gov.

	If you need an accommodation under the Americans with Disabilities Act, call	Page 1
	801-297-3811 or TDD 801-297-2020. Please allow three working days for a response.	Page 1

Section 2 – General Information

Required by all applicants.

2a. Organizational Structure Must check one.

Individual	Government	Corporation	Partnership	LLC/Trust
 Sole Proprietor	 Federal	 C Corp	 General	 LLC  Low Profit LLC
	 State	 S Corp	 Limited	Check the return the LLC files with the IRS
	 Tribal	(Attach copy of	 Limited Liability	 Corp.	 Part.
		IRS approval letter)		 Corp.	 Part.
		IRS approval letter)
	 Political Subdivision	 Non-profit		 Single Member LLC
				Check the return the LLC files with the IRS
				 Indiv.  Corp.  Part.
				 Trust
				Check the return the Trust files with the IRS
				 Fiduc.	 Corp.  Part.

2b. Organization Date Enter the date of qualification or incorporation in Utah: ___________________

(Contact the Dept. of Commerce at 801-530-4849)

2c. Department of Commerce Entity Number Enter number issued by the Dept. of Commerce.

2d. Tax Year End Date: ___________

2e. Federal Identification Number

Every sole proprietor must provide a Social Security Number (SSN). A sole proprietor with employees must also provide an Employer Identification Number (EIN). All other organization types must provide an EIN.

Social Security Number (SSN)

Federal Employer Identification Number (EIN)

2f. Name of Business Entity - PRINT If you are a sole proprietor, write your name here				Daytime phone number

Owner's street address				Cell phone number

City	County	State	Foreign country (if not U.S.)	ZIP Code

Business website address (URL)

2g. DBA/Business Name Business or trade name at this physical location (for additional outlets, fill out form TC-69B)

Physical street address of business (P.O. Box not acceptable)			Business phone number	Fax number

City	County	State	Foreign country (if not U.S.)	ZIP Code

Required: Local Utah government issuing this location’s business license

Lodging services: Will you provide motel, hotel, trailer court, campground or other lodging services at this location?

Yes	No

Cigarette/tobacco: Check all boxes that describe your cigarette/tobacco activities at this location (see section 12b for definitions):
Retailer	 Stamper	 Distributor		 Importer	 PM Mfg			 NPM Mfg	 PACT Act shipper

2h. Business Mailing Address							Email address

City			State	ZIP Code		Foreign country (if not U.S.)			Contact phone number

USTC Use Only

SIC Code

USTC SIC

NAICS

Section 2 continued on Page 3

Page 2

2i. Business Description Describe the nature of your business in detail (include the types of products sold)

Restaurant: If your business is a restaurant, check the box that best describes you:
Fast food	Family restaurant with liquor	Theme with liquor	White table cloth with liquor	Specialty food

2j. Officer/Owner Information

Enter the following information for each officer, general partner, managing member, trustee or enterprise owner. You must provide the SSN of each individual and the EIN of each entity listed (Tax Commission Rule R861-1A-15). The Tax Commission will only discuss account information with those listed. Attach additional sheets if you need more space. Notify the Tax Commission if any changes occur.

Name and Title - PRINT

SSN and EIN

Home Address and City/State/ZIP

Phone Number

SSN

EIN

SSN

EIN

Section 3 – Employer Withholding

3a. When will you start paying wages?

Month Day Year

3c. Annual Filing Option

3b. Estimate the amount of Utah wages you expect to pay in a calendar year:

$16,000 or less

$16,001 - $200,000

$200,001 or more

Will you file employment taxes on Schedule H of your federal income tax return (Form 1040)?

Yes No

Will you file form 944, Employer’s Annual Federal Tax Return?

Yes No

If yes, attach a copy of the IRS notification letter authorizing annual filing.

Section 4 – Mineral Production Withholding

4a. When did you start making mineral production payments?

Month Day Year

Section 5 – Insurance Premium

5a. Are you an admitted insurer who is required to pay tax on premiums received from direct business in Utah? If yes, when did you start writing insurance in Utah?

Month Day Year

Section 6 – Self-Insurer

6a. Are you a self-insured employer? If yes, when did you begin self-insuring in Utah?

Month Day Year

Page 3

Section 7 – Sales and Use Tax

7a. When will you start selling or making purchases?

Month Day Year

7c. If you have a Streamlined Sales Tax (SST) number, enter it here:

7b. Estimate your annual net sales and purchases subject to tax.

$16,000 or less

$16,001 - $800,000

$800,001 - $1,500,000

$1,500,001 or more

Check this box to voluntarily file monthly: 

7d. Are you a cable operator or multi-channel video or audio service provider with no Utah sales tax liability?

Yes No If yes, skip 7e.

7e. Sales and Use Tax

Check each box where your answer is "yes." Notify the Tax Commission if any of the information changes.

1.Will you sell goods or services from only one fixed Utah business location (includes vending machine operators and door-to-door sellers with only one warehouse)?

2.Will you sell goods or services from more than one fixed Utah business location (includes vending machine operators and door-to-door sellers with more than one warehouse)?

•If yes, complete and attach form TC-69B, listing each business location.

3. Will you do one or both of the following:

a.sell goods or services that are shipped from outside Utah to a Utah customer(s)?

b.have goods or materials delivered from outside Utah to a location(s) in Utah other than your fixed place of business?

4. Will you do multi-level marketing?

•If yes, we will send you a Multilevel Marketing Agreement once we have reviewed and processed your application.

5. Will you charge admission or fees for any entertainment, recreation, exhibition, cultural or athletic activity

provided somewhere other than your business location?

6.Will you provide services (cleaning, washing, dry cleaning, repairing or renovating tangible personal property) at non-fixed places of business and not sell tangible personal property?

7.Will you receive recurring payments for leases or rentals of tangible personal property or services?

8.Are you a seller with no physical or representational presence in Utah who is selling goods or services

shipped direct by U.S. mail or common carrier to Utah customers? See Pub 37, Business Activity and Nexus in Utah.

9.Will you sell grocery food? See Pub 25 for the definition of grocery food.

10.Will you sell motor vehicles, aircraft, watercraft, manufactured homes, modular homes or mobile homes in a city or town with the resort communities tax?

The resort communities tax applies to: Alta, Boulder, Brian Head, Bryce Canyon, Garden City, Green River, Independence, Kanab, Midway, Moab, Orderville, Panguitch, Park City, Park City East, Springdale and Tropic

11.Are you a utility providing telephone service, electricity or gas?

•If yes, complete and attach form TC-62Q.

12.Will you have retail sales of new tires? This includes new tires sold as part of a vehicle sale, new tires bought

on or for rented vehicles, and new tires bought from anyone not collecting the Waste Tire Recycling Fee.

13.Will you provide motel, hotel, trailer court, campground or other lodging services for less than 30 consecutive days?

14.Are you a restaurant? See Pub 25 for the definition of restaurant.

15.Will you rent motor vehicles (12,000 pounds or less) to customers for 30 days or less?

16.Will you sell residential fuels (electricity, heat, gas, coal, fuel oil, firewood and other fuels for residential use)?

17.Will you purchase goods or services tax-free from outside Utah that you or your business will store or use

in Utah? See Pub 25 for the definition of use tax.

18. Are you a municipality that generates your own taxable municipal energy,

-OR- do you estimate you will collect municipal energy tax of over $1 million annually?

19.If you did not mark question 18, will you sell taxable municipal energy?

20.Do you provide only the transportation component of taxable energy delivered to the point of sale or use?

21.Will you sell disposable cell phones or disposable cell phone minutes?

22.Will you be the first seller in Utah of lubricating oil in packages of less than 55 gallons?

23.Are you a cable operator or a multi-channel video or audio service provider?

24.Are you a sexually explicit business (see Utah Code §59-27-102)?

25.Will you provide telecommunication services to end consumers?

26.Are you a telephone line provider (radio, land line, VOIP, etc.)?

USTC Use

Only

7d. CAS C/S SWT(VA)

2.A

3.J

4.J (M)

5.J (A)

6.J (S)

7.J (L)

8.J (N)

9.G

10.X

11.U

12.SWT(WT)

13.STR

14.SPF

15.STL

16.(R)

18.STE(ER)

19.STE(E)

20.STE(ET)

21.SWT(CP)

22.SWT(LT)

23.SWT(VA)

24.SWT(SX)

25.SMT

26.SEM

Page 4

Sales Tax Applicants...

	NOTE: You must pay use tax on goods or services you	Temporary Sales Tax License for Special Events
	purchase tax-free and then use. See line 4 of your Sales	You must get a temporary sales tax license any time you
	and Use Tax Return.	You must get a temporary sales tax license any time you
	and Use Tax Return.	participate in a special event, even if you have a permanent sales

	Sales Tax Info	tax license.
	See Pub 25, online at tax.utah.gov/forms, for sales tax	A special event is a one-time event or an event that runs six
	information. Find sales tax rates online at	months or less where sales occur.
	tax.utah.gov/sales/rates.	Examples include fairs, festivals, antique shows, gun shows, food

		shows, art shows, auctions, mall kiosks, swap meets, conventions,
		hobby shows, seasonal stands in malls, and similar events.
		See more information at tax.utah.gov/sales/specialevents, or
		call 801-297-6303, or toll free (outside the Salt Lake area)
		1-800-662-4335, ext. 6303.

Section 8 – Fuel License

8a. Special Fuel Supplier Effective date (mm/dd/yy): _________

Qualifications:	(Check all operations that apply to you. If none, you do not qualify.)
Import diesel	Produce, refine, manufacture	Acquire diesel fuel (not previously
	or blend diesel fuel	taxed) for distribution in Utah
8b.  Motor Fuel	Effective date (mm/dd/yy): _________
Qualifications:	(Check all operations that apply to you. If none, you do not qualify.)

Import motor fuel for use, distribution or sale

Produce, refine, manufacture or compound motor fuel for use, distribution or sale

Purchase motor fuel for resale	 Blend
in wholesale quantities to retail
dealers inside or outside Utah
(does not require a license if all
Utah tax is paid to a Utah
licensed distributor)

8c.  Aviation Fuel Effective date (mm/dd/yy): _________

Qualifications: (Check all operations that apply to you. If none, you do not qualify.)

Import aviation fuel for use, distribution or sale

Make aviation fuel retail sales to both federally certificated air carriers and other persons

Produce, refine, manufacture or compound aviation fuel for use, distribution or sale

Purchase aviation fuel for resale  Blend in wholesale quantities to retail

dealers inside or outside Utah (does not require a license if all Utah tax is paid to a Utah licensed distributor)

8d.  Environmental Assurance Fee Effective date (mm/dd/yy): _________

Qualifications: (Check all operations that apply to you. If none, you do not qualify.)

Import petroleum products for use, distribution or sale

Produce, refine, manufacture or compound petroleum products for use, distribution or sale

8e.  Compressed Natural Gas Effective date (mm/dd/yy): _________

(For suppliers of CNG for highway use. A supplier is an owner or lessor of equipment used to compress natural gas.)

Qualifications: (Check all operations that apply to you. If none, you do not qualify.)

Owner of compression equipment Lessor of compression equipment

8f.  Liquefied Natural Gas Effective date (mm/dd/yy): _________

(For suppliers of LNG for highway use. A supplier is an owner or lessor of equipment used for liquefied natural gas.)

Qualifications: (Check all operations that apply to you. If none, you do not qualify.)

Owner of equipment designed for the use/disbursement of LNG Lessor of equipment designed for the use/disbursement of LNG

Section 8 continued on Page 6

Page 5

8g. Estimate your monthly total taxable gallons for each fuel type you checked.

		50,000 or less	50,001-150,000	150,001-300,000	300,001 or more
1.	Aviation fuel				
2.	Environmental assurance fee				
3.	Motor fuel				
4.	Special fuel				
5.	Compressed Natural Gas*				
6.	Liquefied Natural Gas*				

*Estimate taxable gallons in gasoline gallon equivalents (GGE = 120 cubic feet)

8h. General questions We may deny your license if you do not answer all questions that apply to you.

1. Provide the state, supplier and estimated monthly gallons of fuel imports (attach additional sheets if necessary):

a.Motor fuels

b.Diesel/biodiesel fuels

c.Aviation fuels

d.Other petroleum

State importing from:

_____	Supplier name: _____________	Est. gallons per month: ____
_____	Supplier name: _____________	Est. gallons per month: ____
_____	Supplier name: _____________	Est. gallons per month: ____
_____	Supplier name: _____________	Est. gallons per month: ____

2.How will you report motor, aviation and diesel fuel gallons?

(The basis you choose must stay the same for the calendar year. You may only change your election on January 1.)

Gross election – actual meter amount

Net election – converted to 60 degrees

Section 9 – Mining Severance

9a. When will you start operations in Utah?

Month Day Year

Section 10 – Oil & Gas Conservation and Severance

10a. When will you start operations in Utah?

Month Day Year

10b.DOGM Number

Issued by the Utah Department of Natural Resources:_____________

Section 11 – Radioactive Waste

11a.When will your Utah facility begin operation?

Month Day Year

USTC Use

Only

OGC

OGS

Page 6

Section 12 – Cigarette and Tobacco

12a. When will you start selling or making purchases?

Month Day Year

12b. Business Activities

 Check each box where your answer is "yes." Notify the Tax

Commission if any of the information changes.

1. Will you purchase tobacco products (shisha; moist snuff; RYO, pipe and chewing tobacco; snus; etc.) tax-free for sale in Utah?

•Bond required. Check “Tobacco Products Distributor” on page 1 (1a) and attach bond.

The cash or surety bond value must equal your estimated quarterly tobacco products tax

($500 minimum). The Tax Commission may require you to increase your bond if your actual tax is greater than the estimated amount.

Estimate your tobacco products tax for a quarterly reporting period: $________

2.Will you purchase unstamped cigarettes and affix a Utah stamp prior to sale or distribution?

•Bond required. Check “Cigarette Stamper” on page 1 (1a) and attach bond. The minimum value of the cash or surety bond is $500.

Note: Unpaid cigarette stamp purchases may not exceed 90 percent of your bond value.

3.Will you make retail sales of cigarettes and/or tobacco products (RYO tobacco, shisha, moist snuff, etc.)?

•Signed & notorized affidavit required if:

a)you are not required to post a bond (see questions 1 and 2, above), AND

b)you will sell ONLY stamped cigarettes (no other tobacco products).

The affidavit must state that you will only sell stamped cigarettes.

4.Are you a Participating Manufacturer of cigarettes or RYO tobacco?

5.Are you a Non-participating Manufacturer of cigarettes or RYO tobacco?

6.Will you operate a cigarette rolling machine in Utah?

•Certification required. Attach form TC-550.

USTC Use Only

1.distributor

2.stamper

3.retailer

4.PM mfg

5.NPM mfg

6.RMO

7.PACT

7. Are you subject to the PACT Act and will you ship cigarettes and/or tobacco products into Utah from another state or country?

Multiple Locations: If you will sell cigarettes and/or tobacco products (including vending machine sales) from more than one fixed Utah location, attach form TC-69B, listing each business location. Include $30 per each new location listed.

See Pub 65, Tax Information for Retailers, Distributors and Stampers of Cigarettes and Tobacco Products

Section 13 – Beer

Only complete section 13 if you are a business located in Utah. If you’re an out-of-state supplier with no Utah presence, submit form TC-69N.

13a. When will you start manufacturing or distributing beer in Utah?

Month Day Year

13b. Business Type

 Check all that apply.

1.Beer manufacturer



2.Beer distributor

Page 7

Section 14 – Authorized Signatures	Required by all applicants.

I understand the Tax Commission will review all officers/owners listed in Section 2j (page 3) for previous, unpaid tax debt and I may have to resolve tax issues or post a bond.

I understand any person (including employees, corporate directors, corporate officers, etc.) who has or will have the authority to direct accounting processes or who is required to collect, account for and pay any taxes and fails to do so will be liable for a penalty equal to the total amount of tax not collected, not accounted for or not paid (Utah Code §59-1-302).

I understand I am required to notify the Tax Commission if I add or close a business location; or change the name, organizational structure, officer status or address of the business.

I also understand my signature confirms I have reviewed this section with all those named on this form.

Signature Requirements (for organizational structure checked on line 2a):

• Individual/Sole Proprietor	Signature must match SSN provided in Section 2 (2e)
	(for example, a husband or wife may not sign on behalf of each other).
• All Partnerships	One general partner must sign.
• Corporation / S Corporation	An officer of the corporation authorized to sign on behalf of the corporation must sign.
• Trust	The grantor or a trustee must sign.
• Limited Liability Company / Single Member LLC	A member must sign.
• Government	A government official must sign.

14a. Sole Proprietors Only

You must provide the following information if you are a sole proprietor applying for the tax license(s) shown in Section 1 of this application. Under state and federal law we cannot issue a license to any person who does not provide this information.

If you are a sole proprietor who is not a U.S. citizen, you must file this application IN PERSON at a Tax Commission office.

Check one (providing false information subjects the signer to penalties of perjury):

I am a U.S. citizen and have provided my Social Security Number in Section 2 (2e).

 I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully.	I-94	Number*:	___________________________
Alien Registration		Number*:	___________________________

Employment Authorization Card Number*: ___________________________

*The I-94 (arrival/departure) number and the Alien Registration Number are issued by the U.S. Citizenship and Immigration Service.

Under penalty of perjury, I declare that I am a U.S. citizen OR that I qualify under 8 U.S.C. 1641 and am present in the United States lawfully.

Sole Proprietors Sign Here: __________________________________________	Title:	__________________
Print Name: __________________________________________	Date:	__________________

14b. All Applicants

Under penalty of perjury, I declare that, to the best of my knowledge, the information on this application is true, correct and complete.

ALL APPLICANTS Sign Here: __________________________________________	Title: __________________
Print Name: __________________________________________	Date: __________________

Reporting and Payment Guidelines

Always file tax returns by the due date and pay taxes in full. You must file a return, even if no taxes are due. Enter zero tax, sign and date your return, and file by the due date.

You must file and pay timely, even if you do not receive a preprinted form. Get forms online at tax.utah.gov/forms, at all Tax Commission locations, or by calling the automated forms line at 801-297-6700.

If you do not file a return or pay taxes due, you will be sent a tax delinquency notice and/or contacted. If you disagree with an action taken by the Tax Commission, you may file an appeal within 30 days of receiving the notice. See Pub 2, Utah Taxpayer Bill of Rights.

For questions about EFT payments, see form TC-85 for sales and use tax, or call 801-297-3817. For employer withholding, see Pub 43, or call 801-297-7626.

Question	Answer
Form Name	Utah Form Tc 69
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	utah form tc 131 fill in, Mfg, register for tc 69wth, SSN

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