Form 4924 - Motor Fuel Refund Application
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Missouri Department of Revenue
Form
4924
Motor Fuel Refund Application
Department Use Only - Date Keyed (MM/DD/YYYY): ___ ___ / ___ ___ / ___ ___ ___ ___
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Name
FEIN
Social Security Number
Driver License Number
Physical Address
Mailing Address
City or Town
State
Zip Code
City or Town
State
ZIP Code
County of Physical Address Location of Physical Address (Select One)
E-mail Address
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Inside City Limits
Outside City Limits
Telephone Number
Alternate Telephone Number
Fax Number
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Are you exempt from Missouri sales tax?
Yes
No (If yes, attach a copy of your sales or use tax exemption letter or complete a Sales
or Use Tax Exemption Certificate (Form 149) and submit it along with this form.)
Select all applicable boxes. Review the instructions on back for assistance.
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Agricultural Use
List farm equipment: ______________________________________________________________________________________________
Physical location of farm in Missouri: _________________________________________________________________________________
County: __________________ Number of acres owned or leased: ____________________ Number of acres in cultivation: ____________
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Custom work performed?
Yes
No If yes, type of custom work: ___________________________________________________
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No Farm - Residential or Personal off-road use only (includes residential lawn mowers, ATVs, chain saws, weed eaters, etc.)
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Aviation Use - Provide use type:
Commercial agricultural use
Business use
Recreational use
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Commercial Use (includes lawn care services, golf courses and construction companies)
List off-road equipment: ___________________________________________________________________________________________
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Heating Use
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Home heating % _______________
Business heating %______________
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Ingredient or Component Part - Describe use: _________________________________________________________________________
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Marine Use - List watercraft: _______________________________________________________________________________________
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Motor Fuel Sold To or Purchased By Federal Government
Retailers list the branch name and address of the government agency to whom sales will be made: _______________________________
______________________________________________________________________________________________________________
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Motor Fuel Sold To or Purchased By Public Mass Transportation Operator (Effective 8-28-07)
Retailers list the name and address of the public mass transportation service to whom sales will be made: __________________________
______________________________________________________________________________________________________________
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Power Take-Off (PTO) Use
List type of vehicle operation: ______________________________________________________________________________________
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Reefer Use - Indicate number of reefer units being used: _________________________________________________________________
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Retailer making bulk deliveries to farmers (Effective 1-1-06)
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Must have Agricultural Gasoline Bulk Sale Exemption Certificate (Form 5084) on file.
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Retailer Selling Kerosene
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Barricaded pumps (attach copy of IRS certification)
Non-barricaded pumps in quantities of 21 gallons or less
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Other Usage - Describe use and equipment: __________________________________________________________________________
Gasoline — Road use: ________________________________ Gasoline — Off-road use: ________________________________________
Clear Diesel: ________________________________________ Dyed Diesel: __________________________________________________
$.09 Aviation Gasoline: ________________________________ Other — List product: ____________________________________________
If no bulk storage, explain how fuel is received: ____________________________________________________________________________
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Claimant’s Signature
Typed or Printed Name
Title, if applicable
Date (MM/DD/YYYY)
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Form 4924 (Revised 07-2013)
Mail to:
Taxation Division
Phone: (573) 751-7671
P.O. Box 800
TTY: (800) 735-2966
Visit
Jefferson City, MO 65105-0800
Fax: (573) 522-1720
for additional information.
E-mail:
excise@dor.mo.gov
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