Form Ia 4136 - Fuel Tax Credit For Fiscal Year Filers 2014 Iowa Page 2
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1
22014 IA 4136 page 2
Name(s)
SSN or FEIN
4. Undyed Diesel Fuel
Invoice
Invoice
Highway
Claimed
Tax
Fuel Tax
Sales
Fuel Tax
Date
Gallons
Gallons
Gallons
Rate
Paid
Tax
Credit
01/01/2014
to
4a.
$0.225
$
$
$
02/28/2015
03/01/2015
to
4b.
$0.325
$
$
$
11/30/2015
5. Undyed B11 or Higher
Invoice
Invoice
Highway
Claimed
Tax
Fuel Tax
Sales
Fuel Tax
Date
Gallons
Gallons
Gallons
Rate
Paid
Tax
Credit
07/01/2015
to
5a.
$0.295
$
$
$
11/30/2015
6. Special Fuel - LPG
Invoice
Invoice
Highway
Claimed
Tax
Fuel Tax
Sales
Fuel Tax
Date
Gallons
Gallons
Gallons
Rate
Paid
Tax
Credit
01/01/2014
to
6a.
$0.20
$
$
$
02/28/2015
03/01/2015
to
6b.
$0.30
$
$
$
11/30/2015
7. Total Fuel Tax Credit. Add Fuel Tax Credit column for all fuel types. ................................7. $
*1541005029999*
41-036b (03/04/15)
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