www.iowa.gov/tax
Iowa Department of Revenue
Name(s)
SSN or FEIN
2012 IA 4136
Computation of Iowa Motor Fuel Tax Credit
For calendar year 2012 or fiscal year ended
______________________
, 20
_____
Enclose this form with your Iowa income tax return. See reverse side for instructions.
41-005a (09/20/12)
FUEL USED FOR: [Please check the appropriate box(es)]
 
s
 
1)
Farming  
2)
1. You made no claims for a fuel tax refund on fuel purchased during this tax year.
2. You do not have an active Motor Fuel Tax Refund Permit for this tax year.
3. All information requested on this form must be accurately entered.
4. You must have and maintain records verifying nonhighway gallons purchased.
5. All gallons claimed for credit were paid for in the tax period.
6. The gallons claimed were or will be consumed in other than a registered vehicle.
 
7. Gasoline used in a boat does not qualify for credit unless the boat
was used for commercial fishing.
8. Fuel used in motor vehicles for off-loading procedures does not
qualify for the credit. See instructions for additional information.
9. Sales tax (nonfarm usage) must be computed correctly. See
instructions for additional information.
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.
THE FOLLOWING REQUIREMENTS MUST BE MET  FOR THIS CLAIM TO BE HONORED:
 NOTE: Enclose a copy of federal 4136
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.
s                 s                 s                 s
s
4. Credit. 
Multiply line 3 by the fuel tax
rate
shown above.
$
$                                $                                $
$
5. Less Sales Tax. Non-farm use only. 
See instructions on reverse side.
$
s
$
s
$
s
$
s
$
s
6. Net Amount of Credit.
 
Subtract line 5 from line 4.
$
$                                $                                $
$
7. Total Credit. 
Add line 6, columns A - E
s
$
Commercial
       
3)  Commercial Fishing
       
4) Other (specify)
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