Fillable Printable Form 5084 - Missouri Department Of Revenue
Fillable Printable Form 5084 - Missouri Department Of Revenue
Form 5084 - Missouri Department Of Revenue
Name FEIN or Social Security Number (SSN)
Address
City State ZIP Code Telephone Number
Missouri Department of Revenue
Agricultural Gasoline Bulk Sale Exemption Certificate
Form
5084
Authorized Signature (Purchaser or Purchaser’s Agent)
Under penalties of perjury, I declare that the above information and any attached supplement is true, completed, and correct. I am a farmer as defined in
Section 350.010, RSMo, and the gasoline purchased will be used solely for “agricultural purposes” as defined by Section 142.800, RSMo. The exemption
certificate will be updated every five years with the above named gasoline retailer. I further certify that under penalties of perjury that if any of the gasoline on
said invoice or sales slip is not used as certified above , which will make such fuel subject to the motor fuel law, I shall pay the tax thereon. Should I not so pay
the tax to the Department, then I am liable for all penalties on such purchase, pursuant to the provisions of Chapter 142, RSMo.
Signature
Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
Name Federal Employer Identification Number (FEIN)
Address City State ZIP Code
(__ __ __) __ __ __ - __ __ __ __
Form 5084 (Revised 05-2014)
Taxation Division Phone: (573) 751-7671
P.O. Box 800 Fax: (573) 522-1720
Visit http://www.dor.mo.gov/business/fuel/
for additional information.
All sellers who are engaged as motor fuel retailers and have customers who wish to purchase and have delivered 100 or more gallons of
gasoline for agricultural purposes must secure from their customers and retain in their files a properly executed gasoline bulk sale exemption
certificate, pursuant to Section 142.815.1, RSMo. Such certificates must be updated every five years to substantiate the exempt sales,
and must be made available for inspection by the director of revenue or agents of the director during all business hours of the day.
Seller’s
Information
Purchaser’s
Information
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