Fillable Form 4924 - Motor Fuel Refund Application (Page 2 of 2) in pdf

This Motor Fuel Refund Application (Form 4924) must be completed to substantiate your refund claims. The information will be retained in the

Department of Revenue’s files. If the information changes, please submit a new application with the updated information. Please complete all

information that applies to your situation.

Name and Physical Address: The physical address must be a street or rural route number. Do not enter a Post Office Box number. Please

enter a mailing address if it is different than the physical address.

Federal Employer Identification Number(FEIN), Social Security, or Driver License Number:

County of Physical Address: Enter the county of the claimant’s physical address.

Location of Physical Address: Select either inside or outside the city limits to indicate whether your physical address is located within the

boundaries of a city.

Sales Tax Exemption: Select the appropriate box. If your company is exempt from Missouri state sales tax, attach a copy of your sales or use

tax exemption letter or complete the Sales or Use Tax Exemption Certificate

(Form

149) and submit it with this form.

Agricultural Use: List number and type of farm equipment (i.e., 4 tractors, 1 combine, etc.), the physical location and county where the farm is

located, the number of acres owned or leased, and the number of acres in cultivation. Indicate if you perform custom work and if so, describe

the type of work. This category includes motor fuel used in residential or personal off-road equipment such as lawn mowers, ATV’s, chain

saws, weed eaters, etc.

Aviation Use: Select the box(es) that apply.

Commercial Use: List the number and type of equipment (i.e., 3 bulldozers, 4 caterpillars, 5 lawnmowers, etc.). Include lawn care services, golf

courses, and construction equipment.

Heating Use: Select the box(es) that apply. Indicate the percentage of fuel used for each type of heating. Fuel used for heating a business is

subject to applicable sales tax.

Ingredient or Component Part: Describe the finished product and how the fuel is used as an ingredient or component part.

Marine Use: List the number and type of watercraft (i.e., 2 boats, 1 waverunner, etc.). You are required to complete and submit a Schedule A -

Marine Fuel Purchases by County

(Form

4925) with each refund claim.

Motor Fuel Sold to or Purchased by the Federal Government: Retailers list the branch name and address of the government agency to whom

sales will be made.

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. A Public Mass Transportation Operator Exemption Certificate

(Form

5141) must be

retained in your files.

Power Take-Off Use: List the type of vehicle operation. You are required to complete and submit a Schedule C - Auxiliary Equipment Deduction

Schedule

(Form

588) with each refund claim.

Reefer Use: List the number of reefer units that travel through or in Missouri.

Retailers Making Bulk Deliveries to Farmers: Bulk sales of one hundred gallons or more of gasoline delivered to farmers. An Agricultural

Gasoline Bulk Sale Exemption Certificate

(Form

5084) must be retained in your files.

Retailers Selling Kerosene: Select the box(es) that apply. If the kerosene is being sold through barricaded pumps, submit a copy of the IRS

certification. If the kerosene is being sold through non-barricaded pumps in quantities of 21 gallons or less, you are required to submit the

original invoices or sales slips with each claim.

Other Usage: If you have other situations that are not covered above, describe in detail your operations. List equipment used and how the tax

paid fuel is used for off-road purposes that may qualify for a refund. Attach an additional sheet if needed.

Bulk Storage: Indicate the total storage capacity (tank size) for each product type. If you do not have bulk storage in Missouri, describe how fuel

is received (i.e., fuel is placed directly into equipment from a tank wagon delivery truck, fuel is placed directly into equipment at service

station, etc.)

Claimant’s Signature: Application must be signed and dated. Type or print the name of the person signing the form. Provide title, if applicable.

If you have questions please contact the Missouri Department of Revenue, Taxation Division, P.O. Box 800, Jefferson City, Missouri 65105-0800

or call (573) 751-7671 (TTY (800) 735-2966) or e-mail this office at excise@dor.mo.gov. Visit the Department’s website at

dor.mo.gov/forms

access a copy of this form.

Form 4924 - Motor Fuel Refund Application Page 2

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