Form 5085 - Bulk Deliveries Of Agricultural Gasoline Page 2
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2INSTRUCTIONS FOR BULK DELIVERIES OF AGRICULTURAL GASOLINE
General Instructions
This schedule(s) provides detail in support of the amount(s) shown as bulk deliveries of agricultural gasoline on Form 4923, Motor Fuel Refund Claim.
Each invoice should be listed on a separate line.
If you have questions or need assistance in completing this form, please call (573) 751-7671 or e-mail excise@dor.mo.gov. You may also access the
Department’s web site at
to obtain this form.
Identifying Information
Company Name: Enter the name for the retailer shown on the motor fuel refund claim.
Column Instructions
Column 1:
Date Delivered — Enter the date the product was purchased by the farmer.
Column 2:
Invoice/Ticket Number — Enter the identifying number from the document issued to the farmer when product was delivered.
Column 3:
Name of Purchaser — Enter the name of the purchaser.
Column 4:
Purchaser’s Address — Enter the purchaser’s address (physical location of bulk delivery tank).
Column 5:
Gallons — Enter the gallons of bulk deliveries of agricultural gasoline purchased by the farmer. (Use these figures to complete the Form 4923,
Motor Fuel Refund Claim.)
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