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Get 4923 H Form

NUMBER, OR DRIVER LICENSE NUMBER MAILING ADDRESS CITY OR TOWN, STATE, ZIP CODE TELEPHONE NUMBER ALTERNATE TELEPHONE NUMBER ( ) - FAX NUMBER ( ) - ( ) - E-MAIL ADDRESS AVG PRICE PER GAL (GASOLINE) (see instructions) AVG PRICE PER GAL (CLEAR DIESEL & KEROSENE) (see instructions) The refund claim must be filed w.

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