4923 - H Highway Use Motor Fuel Refund Claim for Rate Increases

Business Name     FEIN

First Name MI Last Name Social Security Number

Spouse’s First Name MI Spouse’s Last Name Spouse’s Social Security Number

Mailing Address City State ZIP Code

Email Address

| | | | | | | |

Missouri Motor Fuel Tax

Increase Paid

(Gallons x $0.075)

10.

11.

12.

Vehicle Identification Number (VIN)

Provide VIN for each Vehicle on

Supporting Worksheet(s)

| | | | | | | |

Use this form to file a refund claim for the Missouri motor fuel tax increase paid beginning July 1, 2023, through June 30, 2024, for motor fuel used for

on road purposes. Refund claims must be postmarked on or after July 1, but no later than September 30 following the fiscal year for which the refund is

claimed. Refund claims for Missouri motor fuel tax paid on fuel purchased for non-highway use must continue to be filed using Non-Highway Use Motor

Fuel Refund Claim (Form 4923).

Vehicle and Fuel Information

Signature Title

Printed Name Date (MM/DD/YYYY)

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 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 and that I am entitled to the refund amount claimed.

__ __ /__ __ /__ __ __ __

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

a. rChecking

rSavings

c. Account Number

| | | | | | | | | | | | | | | |

b. Routing Number

| | | | | | | |

Claimant

Total Gasoline Gallons

(Enter the Rounded

Total for Each Vehicle

from Worksheet(s))

$

Select Box if

Vehicle Does

Not Exceed

26,000 Pounds

Total (Add Lines 1-10. If you have more than 10 vehicles for

which you are filing a claim, see instructions.) ...............

r

Total Diesel Gallons

(Enter the Rounded

Total for Each Vehicle

from Worksheet(s))

Mail to: Taxation Division

PO Box 800

Jefferson City, MO 65105-0800

Phone: (573) 751-7671

Fax: (573) 522-1720

Email: [email protected]

Visit dor.mo.gov/taxation/business/tax-types/motor-fuel/ for additional information.

Form 4923-H (Revised 11-2023)

Ever served on active duty in the United States Armed Forces?

If yes, visit dor.mo.gov/military/ to see the services and benets we offer to all eligible

military individuals. A list of all state agency resources and benets can be found at

veteranbenets.mo.gov/state-benets/.

For Motor Fuel Tax Paid July 1, 2023

through June 30, 2024

Claim must be postmarked July 1, 2024

through September 30, 2024

Refund Claimed (Enter the amount from Line 11) ................................................ $

1.

2.

3.

4.

5.

6.

7.

8.

9.

Form

4923-H

Highway Use Motor Fuel Refund

Claim for Rate Increases

$

Signature

Phone Number

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

| - | | | | | |

Fax Number

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

| | | | | | | | | | | | | | | |

DOR

Only

DLN

DOR

Only

PM Date

Reset Form

Print Form

NEED HELP?

Click here to view video tutorial for this form.

0.00

0

0.00

Complete the worksheet(s) before this section.

Only one fuel type per vehicle may be entered.

Click here for signature information.

Click here to submit refund claim for processing.

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

ZIP Code

State

Date Motor Fuel

Purchased

(MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Claim must be postmarked July 1, 2024 through September 30, 2024 and must accompany Form 4923-H - Highway Use Motor Fuel Refund Claim for

Rate Increases. A separate worksheet must be submitted for each vehicle.

Worksheet of Missouri Motor Fuel Tax Paid by Vehicle

Exact Gallons Purchased

(Carried to 3 decimal

places.)

Seller Name

Seller Address (Street Address)

City

Total

Form 4923-H Worksheet (Revised 11-2023)

Page ____ of ____

4923-H

Worksheet

Type of Fuel (Choose only one) Vehicle Identification Number (VIN) Year Make/Model

| | | | | | | | | | | | | | | |

rClear Diesel rDyed Diesel (see instructions)

/

rGasoline

__ __ /__ __ /__ __ __ __

0.000

Section 142.822 — (Motor Fuel Tax Law)

To claim a refund for the increased portion of the motor fuel tax paid on fuel used for on road purposes, the taxpayer must le a

refund claim. Refund claims must be postmarked on or after July 1, but no later than September 30 following the scal year for

which the refund is claimed. The Worksheet of Missouri Motor Fuel Tax Paid by Vehicle must accompany Form 4923-H. You

must provide a separate worksheet detailing the fuel purchased for each vehicle by vehicle identication number (VIN). Motor

fuel purchased for and consumed by a motor vehicle with a gross weight of 26,000 pounds or less is eligible.

Form Instructions

Lines 1 – 10:

• Vehicle Identication Number (VIN) - Enter the VIN for each vehicle to be claimed for refund.

• Select box if Vehicle Does Not Exceed 26,000 Pounds - Check the box to verify the vehicle claimed for refund has a

gross weight of 26,000 pounds or less. This information can be found on the driver’s side door jam information plate.

• Total Gasoline Gallons - Enter the total gasoline gallons from all Worksheet of Missouri Motor Fuel Tax Paid by

Vehicle forms completed for each VIN. A vehicle cannot have both gasoline gallons and diesel gallons.

• Total Diesel Gallons - Enter the total clear and/or dyed diesel gallons from all Worksheet of Missouri Motor Fuel Tax

Paid by Vehicle forms completed for each VIN. A vehicle cannot have both gasoline gallons and diesel gallons.

• Missouri Motor Fuel Tax Increase Paid - Enter the amount of gallons purchased times (x) the increased portion of the

motor fuel tax rate.

Line 11: Total - Add Lines 1 through 10 for each column. If you have more than 10 vehicles for which you are ling a claim,

electronic ling through the Department’s portal is encouraged to reduce processing time. If you choose to le the

claim via paper, complete an additional Form 4923H and attach the supporting documentation to that form.

Line 12: Refund Claimed - Enter the amount from Line 11.

Worksheet Instructions

• A separate worksheet will need to be submitted for each vehicle claimed. If more than one worksheet is needed for

each vehicle, enter the total from all worksheets on Page 1 for the applicable VIN.

• Type of Fuel - Select only one type per vehicle. If submitting a claim for tax paid on dyed diesel, the claimant must be

a state, city, county, or local government or school district.

• Date Motor Fuel Purchased - Enter the date the fuel was purchased. Fuel must be purchased between July 1 and

June 30 for the reporting period.

• Seller Name - Enter the name of the gas station or company the fuel was purchased from.

• Seller Address - Enter the full address of the seller. This includes the street address, city, state and zip code.

• Gallons Purchased - Enter the exact gallons purchased, including three (3) decimals to the right, as listed on each

invoice or receipt.

Remember to sign and date the form.

Claims received unsigned will be returned.

Claims postmarked before July 1 or after September 30 will be denied.

If you have questions or need assistance in completing this form, please call this office at (573) 751-7671, (TTY (800) 735-2966) or email this

office at: [email protected]. You may also access a copy of this form on the Department’s website: dor.mo.gov/forms.