Clear form
Statement of Utah Tax Withheld on Mineral Production                                                                                 TC-675R
1. Producer’s name, address, city, state and ZIP code                                                                                Rev. 6/13

                                                                                                   For tax year:     20__ __

2. Producer’s federal EIN                             3. Producer’s Utah account number          4. Recipient’s federal EIN (or SSN if an individual)

5. Utah mineral production gross payment to recipient 6. Utah tax withheld on mineral production 7. Utah mineral production gross payment not subject to
                                                                                                 withholding

8. Recipient's name, address, city, state, ZIP code                                              9. Recipient entity type (check one)
                                                                                                 C - Corporation   L - Limited Liability Company
                                                                                                 S - S Corporation O - Limited Liability Partnership
                                                                                                 I - Individual    T,- Trust Estate or Fiduciary
                                                                                                 P - Partnership

All Recipients
The amount of Utah tax withheld on mineral production shown in box 6 should be reported as a refundable tax credit on
your Utah tax return.

TC-40 - Utah Individual Income Tax Return
If filing form TC-40, Utah Individual Income Tax Return, enter the information from this TC-675R on form TC-40W, Part 2.

Individuals receiving Payments through Partnerships, S Corporations and Trusts
If production payments and Utah tax withheld are distributed to you by a partnership, S corporation or trust, a Utah
Schedule K-1 (instead of a form TC-675R) should be furnished by the partnership, S corporation or trust showing your
allocated share of these amounts.

TC-65 - Utah Partnership Return, TC-20S - Utah S Corporation Tax Return, and TC-41 - Utah Fiduciary Tax Return
If you are a Utah partnership, a Utah S corporation, or a Utah fiduciary, and you received a TC-675R or a Utah Schedule
K-1 with a credit for Utah tax withheld on mineral production, the credit must be distributed on the Utah Schedule K-1 you
send to your partners, shareholders, or beneficiaries. Also list the withheld tax credit on TC-250 and attach the form to
your partnership, S corporation, or fiduciary return when filing. Do not issue a separate form TC-675R to show these
amounts. Only producers licensed with the State of Utah for mineral production tax withholding may issue form TC-675R.

Producers Who are Partnerships, S Corporations or Trusts
If you are a mineral producer and withhold tax amounts that are distributed to partners, shareholders or beneficiaries,
you must furnish a Utah TC-675R to each partner, shareholder or beneficiary recipient showing their share amounts of
production payments and Utah tax withheld. Issue separate forms TC-675R to each recipient to show these amounts.

Utah Mineral Production Gross Payment Not Subject to Utah Withholding Tax
The amount shown in box 7 is the amount of the payment made to a recipient that would have been subject to Utah
withholding had the recipient not filed an exemption certificate in accordance with UC Section 59-6-102.1.