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. 1545-01622013 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. 1CRN is credit reference number. (a) Type of use(b) Rate(c) Gallons(d) Amount of credit (e) CRN aOff-highway business use bUse on a farm for farming purposes c$ dExported } 2 Nontaxable Use of Aviation Gasoline (a) Type of use(b) Rate(c) Gallons(d) Amount of credit (e) CRN aUse in commercial aviation (other than foreign trade)$ b cExported dLUST 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 aNontaxable use bUse on a farm for farming purposes$ cUse in trains dUse in certain intercity and local buses (see Caution above line 1) eExported } 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 aNontaxable use taxed at $.244 bUse on a farm for farming purposes$ cUse in certain intercity and local buses (see Caution above line 1) dExported eNontaxable use taxed at $.044 fNontaxable use taxed at $.219 } For Paperwork Reduction Act Notice, see the separate instructions.Cat. No. 12625RForm 4136 (2013) $ .183 .183362 .183 .184411 $ .15354 .193324 .194412 .001433 $ .243 .243360 .243353 .17350 .244413 $ .243 .243346 .17347 .244414 .043377 .218369 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 5Kerosene Used in Aviation (a) Type of use(b) Rate(c) Gallons(d) Amount of credit (e) CRN aKerosene used in commercial aviation (other than foreign trade) taxed at $.244$ bKerosene used in commercial aviation (other than foreign trade) taxed at $.219 cNontaxable use (other than use by state or local government) taxed at $.244 dNontaxable use (other than use by state or local government) taxed at $.219 eLUST tax on aviation fuels used in foreign trade 6 Sales by Registered Ultimate Vendors of Undyed Diesel Fuel Registration No. a of the buyer to make the claim. Claimant certifies that the diesel fuel did not contain visible evidence of dye. Exception. a (b) Rate(c) Gallons(d) Amount of credit (e) CRN aUse by a state or local government$ bUse in certain intercity and local buses 7Sales 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 aUse by a state or local government bSales from a blocked pump$ cUse in certain intercity and local buses } 8Sales by Registered Ultimate Vendors of Kerosene For Use in AviationRegistration No. a to be submitted. (a) Type of use(b) Rate(c) Gallons(d) Amount of credit (e) CRN aUse in commercial aviation (other than foreign trade) taxed at $.219$ bUse in commercial aviation (other than foreign trade) taxed at $.244 cNonexempt use in noncommercial aviation dOther nontaxable uses taxed at $.244 eOther nontaxable uses taxed at $.219 fLUST tax on aviation fuels used in foreign trade Form 4136 (2013) $ .200417 .175355 .243346 .218369 .001433 $ .243360 .17350 $ .243 .243346 .17347 $ .175355 .200417 .025418 .243346 .218369 .001433 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 ReservedRegistration No. a (b) Rate(c) Gallons of alcohol (d) Amount of credit (e) CRN aReserved bReserved 10Biodiesel or Renewable Diesel Mixture CreditRegistration 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 aBiodiesel (other than agri-biodiesel) mixtures$ bAgri-biodiesel mixtures cRenewable 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 aLiquefied petroleum gas (LPG)$ b“P Series” fuels cCompressed natural gas (CNG) (GGE = 126.67 cu. ft.) dLiquefied hydrogen eFischer-Tropsch process liquid fuel from coal (including peat) fLiquid fuel derived from biomass gLiquefied natural gas (LNG) hLiquefied gas derived from biomass 12Alternative Fuel Credit Registration No. a (b) Rate(c) Gallons or gasoline gallon equivalents (GGE) (d) Amount of credit (e) CRN aLiquefied petroleum gas (LPG)$ b“P Series” fuels cCompressed natural gas (CNG) (GGE = 121 cu. ft.) dLiquefied hydrogen eFischer-Tropsch process liquid fuel from coal (including peat) fLiquid fuel derived from biomass gLiquefied natural gas (LNG) hLiquefied gas derived from biomass iCompressed gas derived from biomass (GGE = 121 cu. ft.) Form 4136 (2013) $1.00388 $1.00390 $1.00307 $ .183419 .183420 .183421 .183422 .243423 .243424 .243425 .183435 $ .50426 .50427 .50428 .50429 .50430 .50431 .50432 .50436 .50437 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 13Registered Credit Card IssuersRegistration No. a (b) Rate(c) Gallons(d) Amount of credit (e) CRN aDiesel fuel sold for the exclusive use of a state or local government$ bKerosene sold for the exclusive use of a state or local government cKerosene for use in aviation sold for the exclusive use of a state or local government taxed at $.219 14 Nontaxable Use of a Diesel-Water Fuel Emulsion Caution. There is a reduced credit rate for use in certain intercity and local buses (type of use 5) (see instructions). (a) Type of use(b) Rate(c) Gallons(d) Amount of credit (e) CRN aNontaxable use$ bExported 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 aExported dyed diesel fuel and exported gasoline blendstocks taxed at $.001$ bExported dyed kerosene 17 the proper line of other returns. a17$ Form 4136 (2013) $ .243360 .243346 .218369 $ .197309 .198306 $ .046310 $ .001415 .001416 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----------------