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Utah State Tax Commission                                                                                        TC-43
Voluntary Disclosure Program Application                                                                         Rev. 8/21
                                                                                                                 tax.utah.gov
General Instructions:
 •  Answer all questions in full. If this application is incomplete, it will not be processed.
 •  Save the completed application as a PDF file and email it to nexus@utah.gov.
 •  Email any questions to nexus@utah.gov or call 801-297-4600.

Contact Information (Anonymous applicants: provide contact information for referring agent or agency.)
Contact name                       Company name                  Email address                              Phone

Address                                                   City                                State        ZIP

Applicant Questions
1.  Check your organizational structure
         C Corporation                   S Corporation          Partnership                         LLC
         Sole Proprietor                 Other: ___________
2.  What type of business activity do you conduct in Utah?

3.  Approximately when did you start conducting business in Utah?
        Month        Day           Year

4.  List the type of property you own or lease in Utah:

5.  List all equipment you lease in Utah:

6.  Do you have employees who reside or are stationed in Utah? 
       Yes         No
   If yes, do you have a Withholding tax account?
       Yes         No
7.  Do representatives or independent contractors enter Utah that act on your behalf?
         Yes         No
   If yes, answer the following:
        a. Number of representatives entering Utah     ________________________
        b. Average number of visits per year           ________________________  
        c. Average length of visit                     ________________________

8.  How are Utah sales/business solicited?

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9.  What tax type(s) do you currently file?
      Sales and Use tax                    Corporate Franchise/Income tax                           None
      Withholding tax                      Other tax type: ___________

10.  For which tax type(s) are you requesting relief?
      Sales and Use tax                    Corporate Franchise/Income tax
      Withholding tax                      Other tax type: ___________

11.  If you are requesting relief for only one tax type, why are other tax types not being requested?

12.  Proposed disclosure period (three-year lookback from the current period; if less than three years, back to the start of business or back
to the date Utah nexus began):
a. Sales and Use tax                       ____________________________
b. Corporate Franchise/Income tax          ____________________________
c. Withholding tax                         ____________________________
d. Other tax type: _________               ____________________________

13.  Estimated tax liability you are offering for the disclosure period:
a. Sales and Use tax                       $ ___________________________
b. Corporate Franchise/Income tax          $ ___________________________
c. Withholding tax                         $ ___________________________
d. Other tax type: _________ $ ___________________________

14.  Estimated tax liability you are requesting to be forgiven prior to the disclosure period:
a. Sales and Use tax                       $ ___________________________
b. Corporate Franchise/Income tax          $ ___________________________
c. Withholding tax                         $ ___________________________
d. Other tax type: _________ $ ___________________________

15.  Have you ever collected or withheld Utah taxes?
      Yes          No
If yes:
   a. What tax type? __________
   b. When did you begin collecting or withholding? __________

16.  Have you ever been contacted by the Multistate Tax Commission or by the Utah State Tax Commission?
  Yes            No
If yes, describe the nature of the contact: