Form TC-889 Mineral Production Withholding Tax Exemption Certificate

Expects to claim a refund on a tax return of at least 75% of the amount otherwise required to be deducted and withheld Federal EIN Federal EIN Is required to file a tax return State State Telephone number Telephone number Utah mineral withholding number Zip code Zip code 1 A penalty of 100% of the amount the producer would have deducted and withheld is due i f an exemption certificate was filed and no tax return was filed for the corresponding taxable year If a business is subject to this penalty the taxpayer may not file an exemption certificate for five taxable years beginning with the taxable year the taxpayer is subject to the penalty 2 There is a 5% penalty of the amount a producer would have deducted and withheld if an exemption certificate was filed but the 210 North 1950 West Address Address agency or subdivision No exemption certificate is required for these other entities Auditing Division Complete applicable information in Part 1 Complete applicable information in Part 5 Date signed Exemption certificate shall be filed with the producer and the Tax Commission Penalties: For questions call the Auditing Division Instructions Minerals Section at (801) 297 4600 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 Mineral Production Withholding Name of business Name of company disbursing funds Name of entity claiming exemption Native American or Native American Tribe if the amounts accruing are subject to the supervision of the United States or its Other entities exempt under law from mineral withholding are: Part 1: Name of Producer Part 2: Tax Exempt Entity Information Part 3: Pass Through Entity Information Part 4: Special Exemption Part 5: Authorized Signature Print name of authorized officer refund claim for the taxable year is less than 75% of the amount required to be deducted and withheld Salt Lake City Utah 84134 2300 Send completed original form along with the schedule required for Part 3 (if applicable) to TC 889 Rev 7/08 Send the original of this form and a schedule showing the well number well name and state API number to the Auditing Division This certificate cannot be processed without the schedule Signature of authorized officer Tax Commission Use Only Approved Denied (reason): By The Tax Commission will approve or deny the certificate and return a copy to the company requesting the exemption along with a copy of the well numbers to the company disbursing funds ` Title Under penalty of perjury I certify the above entity is exempt from mineral withholding tax under Utah Code 59 6 102 United States Government or an agency or subdivision of the United States Government; Use Part 2 only if you are exempt from the mineral withholding provisions of the Utah Code Section 59 6 102(2) as an organization exempt from taxes imposed by Utah Code Chapter 7 Corporate Franchise and Income Taxes in accordance with Subsection 59 7 102(1)(a) Use Part 3 only when the recipient of mineral production payments will be making further distributions Use Part 4 if the business entity: Utah State Government or an agency or subdivision of the State of Utah; and Utah State Tax Commission