Form 4136 - Credit For Federal Tax Paid on Fuels (2015)

Form 4136
2014
Credit for Federal Tax Paid on Fuels
Department of the Treasury
Internal Revenue Service (99)
Information about Form 4136 and its separate instructions is at www.irs.gov/form4136.
OMB No. 1545-0162
Attachment
Sequence No. 23
Name (as shown on your income tax return)
Taxpayer identification number
Caution. Claimant has the name and address of the person who sold the fuel to the claimant and the dates of purchase. For
claims on lines 1c and 2b (type of use 13 and 14), 3d, 4c, and 5, claimant has not waived the right to make the claim.
For claims on lines 1c and 2b (type of use 13 and 14), claimant certifies that a certificate has not been provided to the
credit card issuer.
1
Nontaxable Use of Gasoline Note. CRN is credit reference number.
(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN
a
Off-highway business use
b
Use on a farm for farming purposes
c
Other nontaxable use (see Caution above line 1) $
d
Exported
}
2 Nontaxable Use of Aviation Gasoline
(a) Type of use (b) Rate (c) Gallons
(d) Amount of credit
(e) CRN
a
Use in commercial aviation (other than foreign trade) $
b
Other nontaxable use (see Caution above line 1)
c
Exported
d
LUST tax on aviation fuels used in foreign trade
3 Nontaxable Use of Undyed Diesel Fuel
Claimant certifies that the diesel fuel did not contain visible evidence of dye.
Exception. If any of the diesel fuel included in this claim did contain visible evidence of dye, attach an explanation and check here
(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN
a
Nontaxable use
b
Use on a farm for farming purposes $
c
Use in trains
d
Use in certain intercity and local buses (see Caution
above line 1)
e
Exported
}
4 Nontaxable Use of Undyed Kerosene (Other Than Kerosene Used in Aviation)
Claimant certifies that the kerosene did not contain visible evidence of dye.
Exception. If any of the kerosene included in this claim did contain visible evidence of dye, attach an explanation and check here
(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN
a
Nontaxable use taxed at $.244
b
Use on a farm for farming purposes
$
c
Use in certain intercity and local buses (see Caution
above line 1)
d
Exported
e
Nontaxable use taxed at $.044
f
Nontaxable use taxed at $.219
}
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 12625R
Form 4136 (2014)
Page 1/4
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Form 4136 - Credit For Federal Tax Paid on Fuels (2015) PDF

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