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Get Form 4923h - Highway Use Motor Fuel Refund Claim For Rate ...

Last Name Spouse s Social Security Number Claimant Business Name First Name MI Spouse s First Name MI Mailing Address City State Fax Number ( ) - Avg Price Per Gal (Clear Diesel and Kerosene) See Instructions ZIP Code Avg Price Per Gal (Gasoline) See Instructions Email Address The 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.

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