Form 4925 - Schedule A - Marine Fuel Purchases By County

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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4925
P.O. BOX 800, JEFFERSON CITY, MISSOURI 65105-0800
(573) 751-7671
TDD 1-800-735-2966
(REV. 03-2011)
SCHEDULE A — MARINE FUEL PURCHASES BY COUNTY
INSTRUCTIONS: Please enter gallons of gasoline purchased (rounded to the nearest gallon) in each county listed for
marine use. Gasoline purchased in all other counties for marine use should be entered on the line following Wayne County.
Gallons
Gallons
Barry
Monroe
Benton
Morgan
Butler
Ozark
Camden
Polk
Cedar
Ralls
Clay
Reynolds
Clinton
St. Clair
Dade
Stone
Henry
Taney
Hickory
Wayne
Gallons purchased
in all other counties not
Miller
listed:
Total gallons of gasoline purchased for marine use. (Enter this amount on
Line 4 of Form 4923, Motor Fuel Refund Claim.)
0
If you have questions or need assistance in completing this form, please call (573) 751-7671 (TDD 1-800-735-2966)
or e-mail excise@dor.mo.gov. You may also access this form from the Department’s web site:
This publication is available upon request in alternative accessible format(s).
MO 860-2975 (03-2011)

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