Fillable Printable Form 4924 - Motor Fuel Refund Application
Fillable Printable Form 4924 - Motor Fuel Refund Application
Form 4924 - Motor Fuel Refund Application
Form
4924
Missouri Department of Revenue
Motor Fuel Refund Application
Department Use Only - Date Keyed (MM/DD/YYYY): ___ ___ / ___ ___ / ___ ___ ___ ___
Name r FEIN r Social Security Number r 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 (Select One) E-mail Address
r Inside City Limits r Outside City Limits
Telephone Number Alternate Telephone Number Fax Number
Claimant Information
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Are you exempt from Missouri sales tax?
r Yes r No (If yes, attach a copy of your sales or use tax exemption letter or complete a Sales
or Use Tax Exemption Certificate (Form 149) and submit it along with this form.)
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Claimant’s Signature Typed or Printed Name
Title, if applicable Date (MM/DD/YYYY)
Signature
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
r 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? r Yes r No If yes, type of custom work: ___________________________________________________
r No Farm - Residential or Personal off-road use only (includes residential lawn mowers, ATVs, chain saws, weed eaters, etc.)
r Aviation Use - Provide use type: r Commercial agricultural use r Business use r Recreational use
r Commercial Use (includes lawn care services, golf courses and construction companies)
List off-road equipment: ___________________________________________________________________________________________
r Heating Use
r Home heating % _______________ r Business heating %______________
r Ingredient or Component Part - Describe use: _________________________________________________________________________
r Marine Use - List watercraft: _______________________________________________________________________________________
r 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: _______________________________
______________________________________________________________________________________________________________
r 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: __________________________
______________________________________________________________________________________________________________
r Power Take-Off (PTO) Use
List type of vehicle operation: ______________________________________________________________________________________
r Reefer Use - Indicate number of reefer units being used: _________________________________________________________________
r Retailer making bulk deliveries to farmers (Effective 1-1-06)
r Must have Agricultural Gasoline Bulk Sale Exemption Certificate (Form 5084) on file.
r Retailer Selling Kerosene
r Barricaded pumps (attach copy of IRS certification) r Non-barricaded pumps in quantities of 21 gallons or less
r Other Usage - Describe use and equipment: __________________________________________________________________________
Type of Fuel Usage
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: ____________________________________________________________________________
Bulk Storage
(Tank Size)
Mail to: Taxation Division Phone: (573) 751-7671
P.O. Box 800 TTY: (800) 735-2966
Jefferson City, MO 65105-0800 Fax: (573) 522-1720
Visit http://dor.mo.gov/business/fuel/
for additional information.
Form 4924 (Revised 07-2013)
Select all applicable boxes. Review the instructions on back for assistance.
Reset Form
Print Form
This Motor Fuel Refund Application (Form 4924) must be completed to substantiate your refund claims. The information will be retained in the
Department of Revenue’s files. If the information changes, please submit a new application with the updated information. Please complete all
information that applies to your situation.
Name and Physical Address: The physical address must be a street or rural route number. Do not enter a Post Office Box number. Please
enter a mailing address if it is different than the physical address.
Federal Employer Identification Number(FEIN), Social Security, or Driver License Number:
County of Physical Address: Enter the county of the claimant’s physical address.
Location of Physical Address: Select either inside or outside the city limits to indicate whether your physical address is located within the
boundaries of a city.
Sales Tax Exemption: Select the appropriate box. If your company is exempt from Missouri state sales tax, attach a copy of your sales or use
tax exemption letter or complete the Sales or Use Tax Exemption Certificate (Form 149) and submit it with this form.
Agricultural Use: List number and type of farm equipment (i.e., 4 tractors, 1 combine, etc.), the physical location and county where the farm is
located, the number of acres owned or leased, and the number of acres in cultivation. Indicate if you perform custom work and if so, describe
the type of work. This category includes motor fuel used in residential or personal off-road equipment such as lawn mowers, ATV’s, chain
saws, weed eaters, etc.
Aviation Use: Select the box(es) that apply.
Commercial Use: List the number and type of equipment (i.e., 3 bulldozers, 4 caterpillars, 5 lawnmowers, etc.). Include lawn care services, golf
courses, and construction equipment.
Heating Use: Select the box(es) that apply. Indicate the percentage of fuel used for each type of heating. Fuel used for heating a business is
subject to applicable sales tax.
Ingredient or Component Part: Describe the finished product and how the fuel is used as an ingredient or component part.
Marine Use: List the number and type of watercraft (i.e., 2 boats, 1 waverunner, etc.). You are required to complete and submit a Schedule A -
Marine Fuel Purchases by County (Form 4925) with each refund claim.
Motor Fuel Sold to or Purchased by the 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. A Public Mass Transportation Operator Exemption Certificate (Form 5141) must be
retained in your files.
Power Take-Off Use: List the type of vehicle operation. You are required to complete and submit a Schedule C - Auxiliary Equipment Deduction
Schedule (Form 588) with each refund claim.
Reefer Use: List the number of reefer units that travel through or in Missouri.
Retailers Making Bulk Deliveries to Farmers: Bulk sales of one hundred gallons or more of gasoline delivered to farmers. An Agricultural
Gasoline Bulk Sale Exemption Certificate (Form 5084) must be retained in your files.
Retailers Selling Kerosene: Select the box(es) that apply. If the kerosene is being sold through barricaded pumps, submit a copy of the IRS
certification. If the kerosene is being sold through non-barricaded pumps in quantities of 21 gallons or less, you are required to submit the
original invoices or sales slips with each claim.
Other Usage: If you have other situations that are not covered above, describe in detail your operations. List equipment used and how the tax
paid fuel is used for off-road purposes that may qualify for a refund. Attach an additional sheet if needed.
Bulk Storage: Indicate the total storage capacity (tank size) for each product type. If you do not have bulk storage in Missouri, describe how fuel
is received (i.e., fuel is placed directly into equipment from a tank wagon delivery truck, fuel is placed directly into equipment at service
station, etc.)
Claimant’s Signature: Application must be signed and dated. Type or print the name of the person signing the form. Provide title, if applicable.
If you have questions please contact the Missouri Department of Revenue, Taxation Division, P.O. Box 800, Jefferson City, Missouri 65105-0800
or call (573) 751-7671 (TTY (800) 735-2966) or e-mail this office at [email protected]. Visit the Department’s website at dor.mo.gov/forms to
access a copy of this form.
Instructions for Completing Motor Fuel Refund Application
