Part 1 - Utah Withholding Tax Schedule                                                                   TC-40W                 Pg. 1
40109 SSN                                             Last name                                                2021
USTC ORIGINAL FORM

    Line Explanations                                             IMPORTANT

    1  Employer/payer ID number from W-2 box “b” or 1099          Do not send your W-2s or 1099s with your return. Instead enter
    2  Utah withholding ID number from W-2 box “15” or 1099       W-2 or 1099 information below, but only if there is Utah withholding
    (14 characters, ending in WTH, no hyphens)                    on the form.
    3  Employer/payer name and address from W-2 box “c” or 1099
    4  Enter “X” if reporting Utah withholding from form 1099     Use additional forms TC-40W if you have more than four W-2s and/or
    5  Employee’s Social Security number from W-2 box “a” or 1099 1099s with Utah withholding tax.
    6  Utah wages or income from W-2 box “16” or 1099
    7  Utah withholding tax from W-2 box “17” or 1099             Enter mineral production withholding from TC-675R in Part 2 of TC-40W;
                                                                  enter pass-through entity withholding in Part 3 of TC-40W.

First W-2 or 1099                                                 Second W-2 or 1099
 1                                                                1

 2                        (14 characters, no hyphens)             2                                       (14 characters, no hyphens)

 3                                                                3

 4                                                                4

 5                                                                5

 6                    .00                                         6                    .00

 7                    .00                                         7                    .00

 Third W-2 or 1099                                                Fourth W-2 or 1099
 1                                                                1

 2                        (14 characters, no hyphens)             2                                       (14 characters, no hyphens)

 3                                                                3

 4                                                                4

 5                                                                5

 6                    .00                                         6                    .00

 7                    .00                                         7                    .00

                          Enter total Utah withholding tax from all lines 7 here and on TC-40, page 2, line 33: .00

                                                      Submit page ONLY if data entered.
                          Attach completed schedule to your Utah Income Tax Return.
                          Do not attach W-2s or 1099s to your Utah return.

      Mineral Production and Pass-through Withholding                                                    TC-40W Pg. 2
40110 SSN                                             Last name                                          2021
USTC ORIGINAL FORM
Part 2 -Utah Mineral Production Withholding Tax - TC-675R
 Do not send TC-675R or Utah Schedules K-1 with return. Enter TC-675R or Schedule K-1 information below. Use additional TC-40Ws if needed.
   Line Explanations
    1  Producer’s EIN from box “2” of TC-675R                     4  Pass-through entity EIN if credit from partnership or S corporation
    2  Producer’s name from box “1” of TC-675R                      (enter EIN from Utah Schedule K-1)
    3  Producer’s Utah withholding number from box “3” of TC-675R 5  Utah mineral production withholding tax from box”6” of TC-675R or
    (14 characters, ending in WMP, no hyphens)                      from Utah Schedule K-1.
  First TC-675R or Utah Schedule K-1                              Second TC-675R or Utah Schedule K-1
 1                                                                1

 2                                                                2

 3                                   (14 characters, no hyphens)  3                                      (14 characters, no hyphens)

 4                                                                4

 5                      .00                                       5                    .00

Third TC-675R or Utah Schedule K-1                                Fourth TC-675R or Utah Schedule K-1
 1                                                                1

 2                                                                2

 3                                   (14 characters, no hyphens)  3                                      (14 characters, no hyphens)

 4                                                                4

 5                      .00                                       5                    .00

      Enter total mineral production withholding tax from all lines 5 here and on TC-40, page 2, line 36. .00

Part 3 -Utah Pass-through Entity Taxpayer Withholding - Utah Schedule K-1
 Do not send Utah Schedule(s) K-1 with return. Enter information below. Use additional TC-40Ws if needed.
   Line Explanations
   1  Pass-through entity EIN from Utah Schedule K-1 box “A”
   2  Name of pass-through entity from Utah Schedule K-1 box “B”
   3  Utah withholding tax paid by pass-through entity
First Utah Schedule K-1                                           Second Utah Schedule K-1
 1                                                                1

 2                                                                2

 3                      .00                                       3                    .00

Third Utah Schedule K-1                                           Fourth Utah Schedule K-1
 1                                                                1

 2                                                                2

 3                      .00                                       3                    .00

      Enter total pass-through withholding tax from all lines 3 here and on TC-40, page 2, line 35: .00

                                                      Submit page ONLY if data entered.
                                     Attach completed schedule to your Utah Income Tax Return.