Form 4923 - Motor Fuel Refund Claim - Missouri Department Of Revenue
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FOR DOR USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
DIVISION OF TAXATION AND COLLECTION
4923
Document No: ___________________________________________
P O BOX 800
(573) 751-7671
JEFFERSON CITY, MISSOURI 65105-0800
(REV. 1-2003)
Keyed Date: _____________________________________________
MOTOR FUEL REFUND CLAIM
PLEASE PRINT OR TYPE — SEE INSTRUCTIONS ON BACK FOR COMPLETING CLAIM
CLAIMANT’S NAME
FEIN OR SOCIAL SECURITY NUMBER
STREET OR RFD ADDRESS
CITY OR TOWN, STATE, ZIP CODE
MAILING ADDRESS
CITY OR TOWN, STATE, ZIP CODE
TELEPHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
TOTAL GASOLINE GALLONS USED FOR
PURPOSES FOR WHICH OFF-ROAD FUEL IS USED AND
TOTAL CLEAR DIESEL AND KEROSENE FUEL
OFF-ROAD PURPOSES
TAX REFUND IS BEING CLAIMED
GALLONS USED FOR OFF-ROAD PURPOSES
COLUMN A
COLUMN B
1. Agricultural use, fuel used in farm equipment . . . . . . . . . . . . . . . . .
1
2. Commercial use, fuel used in off-road equipment . . . . . . . . . . . . . .
2
3. Reefer use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
4. Marine use (Complete Form 4925, Schedule A,
and attach to claim form.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
5. Power Take-Off (PTO) use, fuel used in auxiliary equipment
(Complete Form 588A, Schedule C, and attach to claim form.) . . .
5
6. Home heating, fuel used for heating purposes . . . . . . . . . . . . . . . .
6
7. Business heating, fuel used for heating purposes . . . . . . . . . . . . .
7
8. Aviation gasoline ($.17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
9. Ingredient or component part of a manufactured product . . . . . . . .
9
10. Retailer selling kerosene through barricaded pumps . . . . . . . . . . . 10
11. Retailer selling kerosene through non-barricaded pumps in
quantities of 21 gallons or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12. Retailer selling fuel to the Federal Government . . . . . . . . . . . . . . . 12
13. Other claims not covered by the above options (explanation
required, attach additional page if necessary):
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________ . . 13
TOTAL GALLONS LISTED IN COL. A, LINES 1-13
TOTAL GALLONS LISTED IN COL. B, LINES 1-13
14.
14
15. $.09 aviation gasoline used for commercial agricultural purposes . 15
16. Gasoline gallons (Line 14, Column A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17. Diesel and kerosene gallons (Line 14, Column B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18. Total gallons (add Lines 16 and 17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
$
19. Total tax paid on gasoline and diesel gallons used for off-road purposes (Line 18 times $.17) . . . . . . . . . . . 19
20. Total tax paid on $.09 aviation gasoline used for commercial agricultural purposes (Line 15, Column A
times $.09) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
$
21. Total amount of refund claimed (add Lines 19 and 20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
$
$
22. Less applicable sales tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
FOR OFFICE
$
23. Total $.17 motor fuel refund approved (Line 21 less Line 22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
USE ONLY
$
24. Total $.09 aviation gasoline refund approved (from Line 20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
DATE STARTED
DATE FINISHED
AUDITOR’S INITIALS
Form 4924 must be on file with our office before we can process this claim.
I, the undersigned, upon my oath, state that I have prepared or reviewed this claim and take full responsibility for the information thereon, that I have made the purchases and used the motor fuel as shown above
and paid the tax on the original invoices attached hereto, that the invoice dates or extensions have not been changed, and that no portion of such motor fuel listed on Line 21 has been or will be used on public
roads of the state of Missouri, and that I am entitled to the refund amount claimed.
CLAIMANT’S SIGNATURE
PRINT NAME
TITLE, IF APPLICABLE
DATE
This form is available upon request in alternative accessible format(s).
MO 860-2973 (1-2003)
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