Form 4136 - Credit For Federal Tax Paid On Fuels - 2015

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4136
OMB No. 1545-0162
Credit for Federal Tax Paid on Fuels
2015
Form
Information about Form 4136 and its separate instructions is at
Attachment
Department of the Treasury
▶
23
(99)
Internal Revenue Service
Sequence No.
Taxpayer identification number
Name (as shown on your income tax return)
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 or 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 or 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
$ .183
b
Use on a farm for farming purposes
.183
362
c
Other nontaxable use (see Caution above line 1)
$
.183
d
Exported
.184
411
2
Nontaxable Use of Aviation Gasoline
(a) Type of use
(b) Rate
(c) Gallons
(e) CRN
(d) Amount of credit
a
Use in commercial aviation (other than foreign trade)
$
$ .15
354
b
Other nontaxable use (see Caution above line 1)
.193
324
c
Exported
.194
412
d
LUST tax on aviation fuels used in foreign trade
.001
433
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
$ .243
b
Use on a farm for farming purposes
$
.243
360
c
Use in trains
.243
353
d
Use in certain intercity and local buses (see Caution
350
above line 1)
.17
e
Exported
.244
413
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
$ .243
b
$
Use on a farm for farming purposes
.243
346
c
Use in certain intercity and local buses (see Caution
347
above line 1)
.17
d
Exported
.244
414
e
Nontaxable use taxed at $.044
.043
377
f
Nontaxable use taxed at $.219
.218
369
4136
For Paperwork Reduction Act Notice, see the separate instructions.
Form
(2015)
Cat. No. 12625R

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