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Nontaxable Use of Gasoline Note. Form 4136 Department of the Treasury Internal Revenue Service (99) Credit for Federal Tax Paid on Fuels a . OMB No. 1545-0162 20 13 Attachment Sequence No. 23 Name (as shown on your income tax return) Taxpayer identification number Caution. credit card issuer. The alternative fuel mixture credit cannot be claimed on this form or on Schedule 3 (Form 8849). It must be taken as a credit against your taxable fuel liability (gasoline, diesel fuel, and kerosene) reported on Form 720. 1 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 $ 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 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. a (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. a (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 (2013) $ .183 .183 362 .183 .184 411 $ .15 354 .193 324 .194 412 .001 433 $ .243 .243 360 .243 353 .17 350 .244 413 $ .243 .243 346 .17 347 .244 414 .043 377 .218 369 Exception. If any of the kerosene included in this claim did contain visible evidence of dye, attach an explanation and check here Exception. If any of the diesel fuel included in this claim did contain visible evidence of dye, attach an explanation and check here Other nontaxable use (see Caution above line 1) Other nontaxable use (see Caution above line 1) For claims on lines 1c and 2b (type of use 13 and 14), claimant certifies that acertificate has not been provided to the claims on lines 1c and 2b (type of use 13 and 14), 3d, 4c, and 5, claimant has not waived theright to make the claim. Claimant has the name and address of the person who sold the fuel to the claimant and the dates ofpurchase. For Information about Form 4136 and its separate instructions is at www.irs.gov/form4136 ----------------Page (0) Break---------------- Form 4136 (2013) Page 2 5 Kerosene Used in Aviation (a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN a Kerosene used in commercial aviation (other than foreign trade) taxed at $.244 $ b Kerosene used in commercial aviation (other than foreign trade) taxed at $.219 c Nontaxable use (other than use by state or local government) taxed at $.244 d Nontaxable use (other than use by state or local government) taxed at $.219 e LUST tax on aviation fuels used in foreign trade 6 Sales by Registered Ultimate Vendors of Undyed Diesel Fuel Registration No. a of the buyer to make the claim. Claimant certifies that the diesel fuel did not contain visible evidence of dye. Exception. a (b) Rate (c) Gallons (d) Amount of credit (e) CRN 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) Registration No. a of the buyer to make the claim. Claimant certifies that the kerosene did not contain visible evidence of dye. Exception. a (b) Rate (c) Gallons (d) Amount of credit (e) CRN 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 Registration No. a 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 $ b Use in commercial aviation (other than foreign trade) taxed at $.244 c Nonexempt use in noncommercial aviation d Other nontaxable uses taxed at $.244 e Other nontaxable uses taxed at $.219 f LUST tax on aviation fuels used in foreign trade Form 4136 (2013) $ .200 417 .175 355 .243 346 .218 369 .001 433 $ .243 360 .17 350 $ .243 .243 346 .17 347 $ .175 355 .200 417 .025 418 .243 346 .218 369 .001 433 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 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 If any of the kerosene included in this claim did contain visible evidence of dye, attach an explanation and check here If any of the diesel fuel included in this claim did contain visible evidence of dye, attach an explanation and check here 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 (see Caution above line 1) ----------------Page (1) Break---------------- Form 4136 (2013) Page 3 9 Reserved Registration No. a (b) Rate (c) Gallons of alcohol (d) Amount of credit (e) CRN a Reserved b Reserved 10 Biodiesel or Renewable Diesel Mixture Credit Registration No. a instructions for line 10 for information about renewable diesel used in aviation. (b) Rate (c) Gallons of biodiesel or renewable diesel (d) Amount of credit (e) CRN a Biodiesel (other than agri-biodiesel) mixtures $ b Agri-biodiesel mixtures c Renewable diesel mixtures 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 (b) Rate (c) Gallons or gasoline gallon equivalents (GGE) (d) Amount of credit (e) CRN a Liquefied petroleum gas (LPG) $ b “P Series” fuels c Compressed natural gas (CNG) (GGE = 126.67 cu. ft.) d Liquefied hydrogen e Fischer-Tropsch process liquid fuel from coal (including peat) f Liquid fuel derived from biomass g Liquefied natural gas (LNG) h Liquefied gas derived from biomass 12 Alternative Fuel Credit Registration No. a (b) Rate (c) Gallons or gasoline gallon equivalents (GGE) (d) Amount of credit (e) CRN a Liquefied petroleum gas (LPG) $ b “P Series” fuels c Compressed natural gas (CNG) (GGE = 121 cu. ft.) d Liquefied hydrogen e Fischer-Tropsch process liquid fuel from coal (including peat) f Liquid fuel derived from biomass g Liquefied natural gas (LNG) h Liquefied gas derived from biomass i Compressed gas derived from biomass (GGE = 121 cu. ft.) Form 4136 (2013) $1.00 388 $1.00 390 $1.00 307 $ .183 419 .183 420 .183 421 .183 422 .243 423 .243 424 .243 425 .183 435 $ .50 426 .50 427 .50 428 .50 429 .50 430 .50 431 .50 432 .50 436 .50 437 D6751 and met EPA•s registration requirements for fuels and fuel additives. The mixture was sold by the claimant to any person foruse as a fuel or was used as a fuel by the claimant. Claimant has attached the Certificate for Biodiesel and, if applicable, the Statement ofBiodiesel The renewable diesel used to produce the renewable diesel mixture was derived from biomass process, met EPA•s registration requirements for fuels and fuel additives, and met ASTM D975, D396, or other equivalent standard approved by the IRS. The mixture was sold by the claimant to any person for use as a fuel or was used as a fuel by the claimant. Claimant hasattached the Certificate for Biodiesel and, if applicable, the Statement of Biodiesel Reseller, both of which have been edited as discussedin the Instructions for Form 4136. See the Reseller. Renewable diesel mixtures. Claimant produced a mixture by mixing renewable diesel with liquid fuel (other thanrenewable diesel). Biodiesel mixtures. Claimant produced a mixture by mixing biodiesel with diesel fuel. The biodiesel used to produce the mixture metASTM ----------------Page (2) Break---------------- Form 4136 (2013) Page 4 13 Registered Credit Card Issuers Registration No. a (b) Rate (c) Gallons (d) Amount of credit (e) CRN 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 government taxed at $.219 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 (b) Rate (c) Gallons (d) Amount of credit (e) CRN a Nontaxable use $ b Exported 15 Diesel-Water Fuel Emulsion Blending Registration No. a (b) Rate (c) Gallons (d) Amount of credit (e) CRN Blender credit $ 16 Exported Dyed Fuels and Exported Gasoline Blendstocks (b) Rate (c) Gallons (d) Amount of credit (e) CRN a Exported dyed diesel fuel and exported gasoline blendstocks taxed at $.001 $ b Exported dyed kerosene 17 the proper line of other returns. a 17 $ Form 4136 (2013) $ .243 360 .243 346 .218 369 $ .197 309 .198 306 $ .046 310 $ .001 415 .001 416 1040, line 70; Form 1120, Schedule J, line 19b; Form 1120S, line 23c; Form 1041, line 24g; or Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and onForm ----------------Page (3) Break----------------