Form Ia 4136 - Computation Of Iowa Motor Fuel Tax Credit - 2013
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1
2Iowa Department of Revenue
Reset Form
2013 IA 4136
For calendar year 2013 or fiscal year ended _______________________ , 20 ______
Computation of Iowa Motor Fuel Tax Credit
Enclose this form with your Iowa income tax return. See reverse side for instructions.
Name(s)
SSN or FEIN
1) Farming
2) Commercial
3) Commercial Fishing
4) Other (specify)
L
FUEL USED FOR: [Please check the appropriate box(es)]
A
B
C
D
E
Fuel Type
Gasoline
Gasohol
E85
Undyed
Special Fuel
Diesel Fuel
(LPG)
Iowa Fuel Tax Rate Per Gallon
21¢
19¢
19¢
22.5¢
20¢
Credit Computation
1.
Number of gallons from original invoices.
2.
Gallons used on highway.
3.
Gallons claimed.
Subtract line 2 from line 1.
L
L
L
L
L
4.
Credit.
Multiply line 3 by the fuel tax
$
$
$
$
$
rate shown above.
5.
Less Sales Tax. Non-farm use only.
$
L $
L $
L $
L $
L
See instructions on reverse side.
6.
Net Amount of Credit.
$
$
$
$
$
Subtract line 5 from line 4.
7.
Total Credit.
Add line 6, columns A - E.
$
L
THE FOLLOWING REQUIREMENTS MUST BE MET FOR THIS CLAIM TO BE HONORED:
1. You made no claims for a fuel tax refund on fuel purchased during this tax year.
7. Gasoline used in a boat does not qualify for credit unless the boat
was used for commercial fishing.
2. You do not have an active Motor Fuel Tax Refund Permit for this tax year.
8. Fuel used in motor vehicles for off-loading procedures does not
3. All information requested on this form must be accurately entered.
qualify for the credit. See instructions for additional information.
4. You must have and maintain records verifying nonhighway gallons purchased.
9. Sales tax (nonfarm usage) must be computed correctly. See
5. All gallons claimed for credit were paid for in the tax period.
instructions for additional information.
6. The gallons claimed were or will be consumed in other than a registered vehicle.
10. Invoices showing gallons must be issued in the name of the
individual, estate, trust, or corporation claiming the credit. See
instructions for partners or S corporation shareholders.
11. A copy of the federal 4136 must also be enclosed with your Iowa
income tax return.
*1341005019999*
NOTE: Enclose a copy of federal 4136
41-005a (07/15/13)
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