Fillable Form 4756 - Affidavit For Loss Of Motor Fuel printable pdf download

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MISSOURI DEPARTMENT OF REVENUE

DLN

FORM

TAXATION DIVISION

4756

P.O. BOX 300, JEFFERSON CITY, MO 65105-0300

(573) 751-2611

TDD (800) 735-2966

(REV. 02-2011)

AFFIDAVIT FOR LOSS OF MOTOR FUEL

SEE INSTRUCTIONS ON REVERSE SIDE — ROUND TO WHOLE GALLONS AND DOLLARS

The director must be notified within ten (10) days from the date of discovery of loss or contamination and this affidavit must be filed within

thirty (30) days of the notification by the person having immediate custody of the motor fuel at the time of the loss or contamination.

CLAIMANT’S NAME

TELEPHONE NUMBER

LICENSE NUMBER (IF APPLICABLE)

FEIN OR SOCIAL SECURITY NO. MONTH/YEAR

__ __ __ __ __ __ __ __ __

__ __ / __ __ __ __

(__ __ __) __ __ __ - __ __ __ __

ADDRESS

P.O. BOX

CITY

STATE

ZIP

___ ___ ___ ___ ___

Exact Location of Loss — If loss occurred while in transit or at time of unloading, give invoice or manifest number below and attach copy

to this claim. If product was returned to terminal attach copy of terminal issued “product return”.

CAUSE OF LOSS

PC — TYPE OF PRODUCT (LIST ONLY ONE PER SHEET)

065 — Gasoline

125 — Aviation Gasoline

285 — Soy Oil

Other

123 — Alcohol

142 — Clear Kerosene

290 — Bio-Diesel – Dyed B100

241 — Ethanol

160 — Clear Diesel Fuel

122 — Blending Components

124 — Gasohol

284 — Bio-Diesel — Undyed B100

(Identify)

Gallons Listed

Product

Date of

Manifest

From Whom Purchased

Number of

Upon Manifest

Code

Loss

Manifest

Number

Company — City, State

Gallons Lost

_ _ / _ _ / _ _ _ _

1. TOTAL GALLONS LOST

2. Allowance — (3% Gasoline, Gasohol, Alcohol, Aviation Gas) (2% Diesel Fuel, Kerosene)

3. Gallons Available for Refund/Credit (Line 1 minus Line 2)

4. Refund/Credit Amount for Gasoline, Gasohol, Alcohol, Diesel Fuel and Kerosene (Line 3 times .17)

5. Refund/Credit Amount for Aviation Gas (Line 3 times .09)

METHOD OR PROCEDURE FOLLOWED IN DETERMINING AMOUNT OF LOSS

Check one

Credit (licensed suppliers only)

Refund

I, the undersigned being first duly sworn, depose and say that I have made the purchases of and paid the tax on the motor fuel as shown above and by

the invoices attached hereto, and that I am entitled to a refund under the provision of Section 142.815(8), RSMo – Motor Fuel Tax Laws. I also declare

under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption,

credit or abatement if I employ such aliens.

PRINT NAME

CLAIMANT’S SIGNATURE

NOTARY

NOTARY PUBLIC EMBOSSER SEAL

STATE

COUNTY (OR CITY OF ST. LOUIS)

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

USE RUBBER STAMP IN CLEAR AREA BELOW

NOTARY PUBLIC SIGNATURE

MY COMMISSION EXPIRES