Form 4136 Form 4136 Credit for Federal Tax Paid on Fuels

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Form

4136

Department of the Treasury
Internal Revenue Service (99)

OMB No. 1545-0162

Credit for Federal Tax Paid on Fuels
▶

Information about Form 4136 and its instructions is available at www.irs.gov/form4136.

2012

Attachment
Sequence No. 23

Taxpayer identification number

Name (as shown on your income tax return)

DRAFT AS OF
November 16, }2012
DO NOT FILE
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

a
b
c
d

2

Off-highway business use
Use on a farm for farming purposes

(b) Rate

(c) Gallons

(d) Amount of credit

$ .183
.183

Other nontaxable use (see Caution above line 1)
Exported

(e) CRN
362

$

.183
.184

411

Nontaxable Use of Aviation Gasoline

(a) Type of use

a
b
c
d

(b) Rate

(c) Gallons

(d) Amount of credit

$ .15*
.193*
.194*

Use in commercial aviation (other than foreign trade)
Other nontaxable use (see Caution above line 1)
Exported

354
324
412

$

.001

LUST tax on aviation fuels used in foreign trade

(e) CRN

433

*See instructions for possible rate changes.

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

Nontaxable use
Use on a farm for farming purposes
Use in trains
Use in certain intercity and local buses (see Caution
above line 1)

.243

353

.17

350

e

Exported

.244

413

4

a
b
c
d

$ .243
.243

$

360

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

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.

(b) Rate

(c) Gallons

$ .243
.243

.17
.244
.043
.218
Cat. No. 12625R

}

(d) Amount of credit
$

(e) CRN
346

347
414
377
369
Form 4136 (2012)

Page 2

Form 4136 (2012)

5

Kerosene Used in Aviation (see Caution above line 1)
(a) Type of use

a

Kerosene used in commercial aviation (other than foreign
trade) taxed at $.244

(b) Rate

(c) Gallons

(e) CRN

(d) Amount of credit
$

$ .200

417

b Kerosene used in commercial aviation (other than foreign

DRAFT AS OF
November 16, 2012
DO NOT FILE
c

trade) taxed at $.219*

.175*

355

Nontaxable use (other than use by state or local
government) taxed at $.244

.243

346

.218*
.001

369
433

d Nontaxable use (other than use by state or local
government) taxed at $.219*

e

6

LUST tax on aviation fuels used in foreign trade
*See instructions for possible rate changes.

Sales by Registered Ultimate Vendors of Undyed Diesel Fuel

Registration No. ▶

Claimant certifies that it sold the diesel fuel at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained the written consent
of the buyer to make the claim. 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

(b) Rate

a Use by a state or local government
b Use in certain intercity and local buses

7

Sales by Registered Ultimate Vendors of Undyed Kerosene (Other
Than Kerosene For Use in Aviation)

(c) Gallons

.

.

.

(d) Amount of credit

$ .243
.17

▶

(e) CRN

360
350

$

Registration No. ▶

Claimant certifies that it sold the kerosene at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained the written consent of the
buyer to make the claim. 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 .

(b) Rate

a Use by a state or local government
b Sales from a blocked pump
c Use in certain intercity and local buses

8

Sales by Registered Ultimate Vendors of Kerosene For Use in Aviation

$ .243
.243
.17

(c) Gallons

}

.

.

(d) Amount of credit
$

.

▶

(e) CRN

346
347

Registration No. ▶

Claimant sold the kerosene for use in aviation at a tax-excluded price and has not collected the amount of tax from the buyer, repaid the
amount of tax to the buyer, or has obtained the written consent of the buyer to make the claim. See the instructions for additional information
to be submitted.
(a) Type of use (b) Rate
(c) Gallons
(d) Amount of credit (e) CRN

a

Use in commercial aviation (other than foreign trade) taxed
at $.219*

$ .175*

$

355

b Use in commercial aviation (other than foreign trade) taxed
at $.244

c
d
e
f

Nonexempt use in noncommercial aviation
Other nontaxable uses taxed at $.244
Other nontaxable uses taxed at $.219*
LUST tax on aviation fuels used in foreign trade
*See instructions for possible rate changes.

.200
.025*
.243
.218*
.001

417
418
346
369
433
Form 4136 (2012)

Page 3

Form 4136 (2012)

9

Reserved

Registration No. ▶

(b) Rate

(c) Gallons of
alcohol

(d) Amount of credit

(e) CRN

(d) Amount of credit

(e) CRN

(c) Gallons
(d) Amount of credit
or gasoline
gallon
equivalents (GGE)

(e) CRN

DRAFT AS OF
November 16, 2012
DO NOT FILE
a Reserved
b Reserved

10

Reserved

Registration No. ▶

Reserved

(b) Rate

(c) Gallons of
biodiesel or
renewable
diesel

a Reserved
b Reserved
c Reserved

11

Nontaxable Use of Alternative Fuel
Caution. There is a reduced credit rate for use in certain intercity and local buses (type of use 5) (see instructions).

(a) Type of use

a
b
c
d
e

Liquefied petroleum gas (LPG)
“P Series” fuels
Compressed natural gas (CNG) (GGE = 126.67 cu. ft.)
Liquefied hydrogen
Any liquid fuel derived from coal (including peat) through the
Fischer-Tropsch process

f Liquid fuel derived from biomass
g Liquefied natural gas (LNG)
h Liquefied gas derived from biomass
12

Alternative Fuel Credit and Alternative Fuel Mixture Credit

a
b
c
d
e

(b) Rate

$ .183
.183
.183
.183

$

419
420
421
422

.243
.243
.243
.183

423
424
425
435

Registration No. ▶
(b) Rate

(c) Gallons
(d) Amount of credit
or gasoline
gallon
equivalents (GGE)

(e) CRN

$ .50

$

429

Reserved
Reserved
Reserved
Liquefied hydrogen
Reserved

f
g
h
i

Reserved
Reserved
Reserved
Reserved
Form 4136 (2012)

Page 4

Form 4136 (2012)

13

Registered Credit Card Issuers

Registration No. ▶
(b) Rate

a Diesel fuel sold for the exclusive use of a state or local government
b Kerosene sold for the exclusive use of a state or local government
c Kerosene for use in aviation sold for the exclusive use of a state or local

(c) Gallons

(d) Amount of credit
$

$ .243
.243

(e) CRN

360
346

DRAFT AS OF
November 16, 2012
DO NOT FILE
government taxed at $.219*

.218*

369

*See instructions for possible rate changes.

14

Nontaxable Use of a Diesel-Water Fuel Emulsion

Caution. There is a reduced credit rate for use in certain intercity and local buses (type of use 5) (see instructions).

(a) Type of use

a Nontaxable use
b Exported

15

Diesel-Water Fuel Emulsion Blending

(b) Rate

16

(d) Amount of credit

$

$ .197
.198

(e) CRN
309
306

Registration No. ▶

(b) Rate

Blender credit

(c) Gallons

(c) Gallons

$ .046

(d) Amount of credit

(e) CRN

310

$

Exported Dyed Fuels and Exported Gasoline Blendstocks
(b) Rate

a Exported dyed diesel fuel and exported gasoline blendstocks taxed at $.001
b Exported dyed kerosene

17

(c) Gallons

$ .001
.001

Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and on Form
1040, line 70; Form 1120, Schedule J, line 19b; Form 1120S, line 23c; Form 1041, line 24g; or
the proper line of other returns. ▶

(d) Amount of credit
$

(e) CRN
415
416

17 $
Form 4136 (2012)