Form 4924 - Motor Fuel Refund Application - 2011
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2FOR DOR USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
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4924
P O BOX 800, JEFFERSON CITY, MISSOURI 65105-0800
(573) 751-7671
TDD (800) 735-2966
(REV. 03-2011)
Keyed Date: ___________________________________
MOTOR FUEL REFUND APPLICATION
PLEASE PRINT OR TYPE — SEE INSTRUCTIONS ON BACK
CLAIMANT’S NAME
FEIN, SOCIAL SECURITY NUMBER OR 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 (Check One)
E-MAIL ADDRESS
INSIDE CITY LIMITS
OUTSIDE CITY LIMITS
TELEPHONE NUMBER
ALTERNATE TELEPHONE NUMBER
FAX NUMBER
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
Are you exempt from Missouri sales tax?
Yes
No
(If yes, attach a copy of your sales/use tax exemption letter or complete
the Form 149, Sales/Use Tax Exemption Certificate and submit it along with this form.)
Please check all applicable boxes. Please review instructions on back.
Agricultural Use
List farm equipment: _______________________________________________________________________________________________
Physical location of farm in Missouri: __________________________________________________________________________________
County: _________________________________________________________________________________________________________
Number of acres owned or leased: _______________________
Number of acres in cultivation: ___________________________
Custom work performed?
Yes
No
Type of custom work: __________________________________
No Farm - Residential/Personal off-road use only (includes residential lawn mowers, ATV’s, chain saws, weed eaters, etc.)
Commercial Use - (Includes lawn care services, golf courses and construction companies).
List off-road equipment: _____________________________________________________________________________________________
Reefer Use
Indicate number of reefer units being used: _____________________________________________________________________________
Marine Use
List watercraft: ____________________________________________________________________________________________________
Power Take-Off (PTO) Use
List type of vehicle operation: ________________________________________________________________________________________
Heating Use
Home heating % ____________
Business heating % _____________
Aviation Use
Commercial agricultural use
Business use
Recreational use
Ingredient or Component Part
Describe use: ____________________________________________________________________________________________________
Retailer making bulk deliveries to farmers (Effective 1-1-06)
Must have Agricultural Gasoline Bulk Sale Exemption Certificate (Form 5084) on file.
Retailer Selling Kerosene
Barricaded pumps (attach copy of IRS certification)
Non-barricaded pumps in quantities of 21 gallons or less
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: _________________________________
________________________________________________________________________________________________________________
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: ____________________________
________________________________________________________________________________________________________________
Other Usage - Describe use and equipment: ____________________________________________________________________________
BULK FUEL STORAGE CAPACITY (TANK SIZE):
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: ____________________________________________________________________
CLAIMANT’S SIGNATURE
PRINT NAME
TITLE, IF APPLICABLE
DATE
__ __ /__ __ /__ __ __ __
This publication is available upon request in alternative accessible format(s).
MO 860-2974 (03-2011)
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Parent category: Financial