Form 4755 - Notification Of Loss Of Motor Fuel Page 2
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2NOTIFICATION OF LOSS OF MOTOR FUEL
General Instructions
This form is to be used when notifying the department of any loss of tax-paid motor fuel lost due to a sudden and unexpected casualty or
which had been accidentally contaminated as to be unsalable as highway fuel.
As provided for in Section 142.815.2(8), RSMo,
“Motor fuel which was purchased tax paid and which was lost or destroyed as a direct result of a sudden and unexpected casualty or
which had been accidentally contaminated so as to be unsalable as highway fuel as shown by proper documentation as required by
the director. The exemption pursuant to this subdivision shall be refunded to the person or entity owning the motor fuel at the time of
the contamination or loss. Such person shall notify the director in writing of such event and the amount of motor fuel lost or
contaminated within ten days from the date of discovery of such loss or contamination, and within thirty days after such
notice, shall file an affidavit sworn to by the person having immediate custody of such motor fuel at the time of the loss or contamina-
tion, setting forth in full the circumstances and the amount of the loss or contamination and such other information with respect
thereto as the director may require”.
This form is used for notification purposes only. An Affidavit for Loss of Motor Fuel must be submitted to obtain credit or refund.
If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov. You may also
access the department’s web site at to obtain this form.
Identifying Information
Enter company name, address, telephone number, license number (if licensed as a motor fuel supplier, permissive supplier or distributor) and
FEIN or social security number.
Enter information for the motor fuel lost.
This publication is available upon request in alternative accessible format(s).
MO 860-2834 (11-2006)
NOTIFICATION OF LOSS OF MOTOR FUEL
General Instructions
This form is to be used when notifying the department of any loss of tax-paid motor fuel lost due to a sudden and unexpected casualty or
which had been accidentally contaminated as to be unsalable as highway fuel.
As provided for in Section 142.815.2(8), RSMo,
“Motor fuel which was purchased tax paid and which was lost or destroyed as a direct result of a sudden and unexpected casualty or
which had been accidentally contaminated so as to be unsalable as highway fuel as shown by proper documentation as required by
the director. The exemption pursuant to this subdivision shall be refunded to the person or entity owning the motor fuel at the time of
the contamination or loss. Such person shall notify the director in writing of such event and the amount of motor fuel lost or
contaminated within ten days from the date of discovery of such loss or contamination, and within thirty days after such
notice, shall file an affidavit sworn to by the person having immediate custody of such motor fuel at the time of the loss or contamina-
tion, setting forth in full the circumstances and the amount of the loss or contamination and such other information with respect
thereto as the director may require”.
This form is used for notification purposes only. An Affidavit for Loss of Motor Fuel must be submitted to obtain credit or refund.
If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov. You may also
access the department’s web site at to obtain this form.
Identifying Information
Enter company name, address, telephone number, license number (if licensed as a motor fuel supplier, permissive supplier or distributor) and
FEIN or social security number.
Enter information for the motor fuel lost.
This publication is available upon request in alternative accessible format(s).
MO 860-2834 (11-2006)
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