Fillable Form 4923 - Motor Fuel Refund Claim printable pdf download

Missouri Department of Revenue

Form

4923

Motor Fuel Refund Claim

Office Use Only Keyed Date: ___________________ Document No: _______________________________

Name

FEIN

Social Security Number

Driver License Number

Mailing Address

City

State

Zip Code

Phone Number

Alternate Phone Number

Fax Number

(___ ___ ___)___ ___ ___-___ ___ ___ ___

E-mail Address

Avg Price Per Gal (Gasoline)

Avg Price Per Gal (Clear Diesel and Kerosene)

(See instructions)

(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 the Department 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. Please submit original invoices.

Total Clear Diesel and

Total Gasoline Gallons

Kerosene Gallons

Purposes for which Off-Road fuel is used

Column A

Column B

Agricultural use, fuel used in farm equipment, lawn mower, etc. .........................

Commercial or construction use, fuel used in off-road equipment .......................

Reefer use ............................................................................................................

Marine use (Complete

Form 4925, Schedule

A, and attach to claim form.) .......

Power Take-Off (PTO) use, fuel used in auxiliary equipment

Form 588, Schedule

C, and attach) .................................................

(Complete

Home heating, fuel used for heating purposes .....................................................

Business heating, fuel used for heating purposes ................................................

Motor fuel used in aircraft engines ($.17) .............................................................

Ingredient or component part of a manufactured product ....................................

Retailer making bulk deliveries to farmers............................................................

Retailer selling kerosene through barricaded pumps ...........................................

Retailer selling kerosene through non-barricaded pumps (21 gallons or less).....

Motor Fuel sold to or purchased by Federal Government ...................................

Motor Fuel sold to or purchased by public mass transportation operator ....................

Other claims not covered by the above options (attach additional page) .............

16. Gasoline gallons (Total; Column A Lines 1 through 15) .....................................................................................

17. Clear diesel and kerosene gallons (Total; Column B Lines 1 through 15) ..........................................................

18. Total gallons (add Lines 16 and 17) ....................................................................................................................

19. Less eligible purchaser allowance gallons ..........................................................................................................

20. Total gallons (Line 18 minus Line 19) .................................................................................................................

21. Total tax paid on gasoline and clear diesel gallons used for off-road purposes (Line 20 multiplied by $.17) .........

22. Total $.09 aviation fuel gallons used for commercial agricultural purposes .............................

23. Total tax paid on $.09 aviation fuel used for commercial agricultural purposes (Line 22 multiplied by $.09) .....

24. Total amount of refund claimed (add Lines 21 and 23) ......................................................................................

25. Less applicable sales tax for gasoline and aviation fuel ..........................................................

Office Use

26. Less applicable sales tax for clear diesel and kerosene ..........................................................

Only

27. Total $.17 motor fuel refund approved .....................................................................................

28. Total $.09 aviation fuel refund approved ..................................................................................

If you would like your refund deposited directly to your checking or savings account, complete boxes a, b, and c below.

Checking

b. Account Number

a. Routing Number

Savings

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. I state that I have prepared

or reviewed this claim and take full responsiblity 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.

Signature

Title

Printed Name

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Form 4923 (Revised 11-2013)

Mail to:

Phone: (573) 751-7671

Taxation Division

Visit

P.O. Box 800