Form 4756 - Affidavit For Loss Of Motor Fuel Page 2
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2AFFIDAVIT FOR LOSS OF MOTOR FUEL
Instructions
This form is to be completed when claiming credit or requesting a refund for tax paid on motor fuel lost or destroyed due to a
sudden and unexpected casualty or contamination which makes the fuel unsalable as highway fuel.
Suppliers will be issued credit to be used on their monthly tax report. All other claimants will be issued a refund.
This affidavit must be submitted within thirty (30) days following notification of the loss to the department pursuant to 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 unex-
pected 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 contamination, setting forth in full the circum-
stances and the amount of the loss or contamination and such other information with respect thereto as the
director may require”.
General Instructions
Enter the name, numbers and information for the claimant. If claimant holds a Missouri supplier, permissive supplier or distributor
license, provide license number.
Enter the details for loss.
Print name and sign the form.
Notarize form.
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.
MO 860-2835 (11-2006)
This publication is available upon request in alternative accessible format(s).
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