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4923 - Non-Highway Use Motor

Office Use ONLYThe 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. Name Email Address r FEIN r Social Security NumberMailing Address City State ZIP Code Fax Number (___ ___ ___)___ ___ ___-___ ___ ___ ___ClaimantAlternate Phone Number (___ ___ ___)___ ___ ___-___ ___ ___ ___Phone Number (___ ___ ___)___ ___ ___-___ ___ ___ ___ | | | | | | | | | | Form4923 Non-Highway Use Motor Fuel Refund Claim Purposes for which off-road fuel is used.

Sep 30, 2021 · Clear Diesel/Clear Kerosene. Purchaser. r . Aviation Gasoline (see Instructions) Address of Seller (street, city, state, zip) Form 4923 (Revised 12-2021) Totals (for this page only) A separate worksheet must be completed for each fuel type by usage and must accompany Form 4923 - Non-Highway . Use Motor Fuel Refund Claim.

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