Form 4923 - Motor Fuel Refund Claim
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1
2FOR DOR USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
Reset Form
Print Form
4923
P.O. BOX 800
(573) 751-7671
Document No: ___________________________________________
JEFFERSON CITY, MISSOURI 65105-0800
(REV. 04-2011)
Keyed Date: _____________________________________________
MOTOR FUEL REFUND CLAIM
PLEASE PRINT OR TYPE — SEE INSTRUCTIONS ON BACK FOR COMPLETING CLAIM
CLAIMANT’S NAME
FEIN, SOCIAL SECURITY NUMBER, OR DRIVER LICENSE NUMBER
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __
MAILING ADDRESS
CITY OR TOWN, STATE, ZIP CODE
TELEPHONE NUMBER
ALTERNATE TELEPHONE NUMBER
FAX NUMBER
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
E-MAIL ADDRESS
AVG PRICE PER GAL (GASOLINE) (see instructions)
AVG PRICE PER GAL (CLEAR DIESEL & KEROSENE)
(see instructions)
The refund claim must be filed within one year of the date of purchase or April 15 following the year of purchase, whichever is later.
Form 4924 must be on file with our office or submitted at the same time as Form 4923, in order to process this claim.
Verify proper address above, as refund checks cannot be forwarded.
TOTAL GASOLINE GALLONS USED FOR
PURPOSES FOR WHICH OFF-ROAD FUEL IS USED AND
TOTAL CLEAR DIESEL AND KEROSENE
OFF-ROAD PURPOSES
TAX REFUND IS BEING CLAIMED
GALLONS USED FOR OFF-ROAD PURPOSES
ROUND ALL GALLONS TO NEAREST GALLON
COLUMN A
COLUMN B
1. Agricultural use, fuel used in farm equipment, lawn mower, etc.
1.
2. Commercial/construction use, fuel used in off-road equipment ..
2.
3. Reefer use ..................................................................................
3.
4. Marine use (Complete Form 4925, Schedule A,
and attach to claim form.) ...........................................................
4.
5. Power Take-Off (PTO) use, fuel used in auxiliary equipment
(Complete Form 588A, Schedule C, and attach to claim form.) .
5.
6. Home heating, fuel used for heating purposes ...........................
6.
7. Business heating, fuel used for heating purposes ......................
7.
8. Motor fuel used in aircraft engines ($.17) ...................................
8.
9. Ingredient or component part of a manufactured product ..........
9.
10. Retailer making bulk deliveries to farmers (effective 1-1-06) ......
10.
11. Retailer selling kerosene through barricaded pumps ..................
11.
12. Retailer selling kerosene through non-barricaded pumps in
quantities of 21 gallons or less ....................................................
12.
13. Motor Fuel sold to or purchased by Federal Government ..........
13.
14. Motor Fuel sold to or purchased by public mass transportation operator
(effective 8-28-07)..........................................................................
14.
15. Other claims not covered by the above options (explanation
required, attach additional page if necessary): ..............................
15.
___________________________________________________
TOTAL GALLONS LISTED IN COL. A, LINES 1-15
TOTAL GALLONS LISTED IN COL. B, LINES 1-15
0
0
__________________________________________________
16.
16.
17. $.09 aviation fuel used for commercial agricultural purposes ........
17.
0
18. Gasoline gallons (Line 16, Column A)
18.
0
19. Clear diesel and kerosene gallons (Line 16, Column B)
19.
20. Total gallons (add Lines 18 and 19)
20.
21. Less eligible purchaser allowance gallons
21.
22. Total gallons (Line 20 minus Line 21)
22.
23. Total tax paid on gasoline and clear diesel gallons used for off-road purposes (Line 22 multiplied by $.17)
23.
$
24. Total tax paid on $.09 aviation fuel used for commercial agricultural purposes (Line 17, Column A
$
multiplied by $.09)
24.
25. Total amount of refund claimed (add Lines 23 and 24)
25.
$
$
26
Less applicable sales tax for gasoline .............................................................................
26.
$
FOR OFFICE
27. Less applicable sales tax for clear diesel and kerosene .................................................
27.
USE ONLY
$
28. Total $.17 motor fuel refund approved (Line 25 less Line 26 and Line 27) ....................
28.
$
29. Total $.09 aviation fuel refund approved (from Line 24) .................................................
29.
I, the undersigned, upon my oath, state that I have prepared or reviewed this claim and take full responsibility for the information thereon, that I have made the purchases and used the motor fuel as
shown above and paid the tax on the original invoices attached hereto, that the invoice dates or extensions have not been changed, and that no portion of such motor fuel listed on Line 25 has been
or will be used on public roads of the state of Missouri, and that I am entitled to the refund amount claimed. 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.
CLAIMANT’S SIGNATURE
PRINT NAME
TITLE, IF APPLICABLE
DATE
__ __ / __ __ / __ __ __ __
MO 860-2973 (04-2011)
This form is available upon request in alternative accessible format(s).
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