Utah State Tax Commission
                                                                        Affidavit of                                            TC-757
                                                                                                                              Rev. 12/95
                                                                       Out-of-State Delivery

                                                                                              Clear form Print Form

  Complete this form whenever merchandise sold by a Utah vendor is physically delivered by the vendor to a point outside
  Utah by the vendor or the vendor's employee, as a required part of the sale. This form must be kept by the seller to verify
  sales tax exemption due to out-of-state delivery. Maintain this form with your records; do not send it to the Tax Commission.

  For additional information or assistance, please contact the Utah State Tax Commission, 210 North 1950 West, Salt Lake
  City, Utah 84134, telephone (801) 297-2200, or 1-800-662-4335 if outside the Salt Lake area.

                        Sales Tax Exemption Based Upon Out-of-State Delivery

Sale Information
Customer's name                                                                           Seller's invoice number Invoice date

Destination                                                                                      Customer's telephone number

Section 1 Port of Entry Personnel Certification of Out-of-State Delivery

This is to certify that I personally examined the property listed on the seller's invoice.
Port of entry signature                      Date signed               Port of entry location    Telephone number

X This form must be signed by hand after it is printed.
Section 2 Out-of-State Delivery Verification Attach copies of driver's log, fuel purchase receipts, motel and other expenses.

This is to certify that I personally delivered the merchandise described on the seller's invoice to the destination shown above.
Delivery signature                           Date signed Title
X
  This form must be signed by hand after it is printed.
Section 3 Purchaser's Declaration of Out-of-State Acceptance

I certify, under the penalties of perjury, that merchandise described on this affidavit was accepted outside the State of Utah. As the
purchaser, I understand that if there is a use tax liability on this merchandise, it is to be reported and paid to the seller (if the seller is
licensed to collect tax for this state) or directly the Tax Commission.

Delivery signature                           Date signed Title
X
  This form must be signed by hand after it is printed.

                        Print Form

  IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.                 Clear form