EFTA01222686.pdf

OMB No. 1545-0162 Fom4136 Credit for Federal Tax Paid on Fuels 2017 Department of the Treasury ► Go to wwwirs.gov/Form4136 for Instructions and the latest information. Attachment Internal Revenue Service (9) Sequence No. 23 Name (as shown on your income tax ream) Taxpayer Identification number 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 lc 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 lc 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 (d) Amount of credit (e) CRN a Use in commercial aviation (other than foreign trade) $ .15 $ 354 b Other nontaxable use (see Caution above tine 1) .193 324 c Exported .194 412 d LUST tax on aviation fuels used in foreign trade s_ .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 BP' (a) Type of use (2) Rate (c) Gallons (d) Amount of credit (e) CRN a Nontaxable use $ .243 b Use on a farm for farming purposes .243 1 $ 360 c Use in trains .243 353 d Use in certain intercity and local buses (see Caution above line 1) .17 350 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 ► 0 (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 1 $ 346 c Use in certain intercity and local buses (see Caution above line 1) .17 347 d Exported .244 414 e Nontaxable use taxed at $.044 .043 377 f Nontaxable use taxed at $.219 .218 369 For Paperwork Reduction Act Notice, see the separate instructions. Form 4136 (2017) EFTA01222686 Foim 4136(2017) Page 2 5 Kerosene Used in Aviation (see Caution above line 1) (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 $ .200 $ 417 b Kerosene used in commercial aviation (other than foreign trade) taxed at $.219 .175 355 c Nontaxable use (other than use by state or local government) taxed at $.244 .243 3441 d Nontaxable use (other than use by state or local government) taxed at $.219 .218 369 e LUST tax on aviation fuels used in foreign trade .001 433 6 Sales by Registered Ultimate Vendors of Undyed Diesel Fuel Registration No. IP. 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 Is• 0 (b) Rate (c) Gallons (d) Amount of credit (e) CRN a Use by a state or local govemment $ .243 $ 360 b Use in certain intercity and local buses .17 350 7 Sales by Registered Ultimate Vendors of Undyed Kerosene (Other Than Kerosene For Use in Aviation) Registration No. PIP. 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 ► 0 (b) Rate (c) Gallons (d) Amount of credit (e) CRN a Use by a state or local govemment $ .243 b Sales from a blocked pump .243 1 $ 346 c Use in certain intercity and local buses .17 347 8 Sales by Registered Ultimate Vendors of Kerosene For Use in Aviation 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 .200 417 c Nonexempt use In noncommercial aviation 025 418 d Other nontaxable uses taxed at $.244 .243 346 e Other nontaxable uses taxed at $.219 .218 369 f LUST tax on aviation fuels used in foreign trade .001 433 Form 4136 (201n EFTA01222687 Form 4136(2017) Page 3 9 Reserved for future use Registration No. ► (b) Rate (c) Gallons of I (d) Amount of credit (e) CRN alcohol a sserved for future use b saerved for future use 10 Biodiesel or Renewable Diesel Mixture Credit Registration No. ► Biodiesel's mixtures. Claimant produced a mixture by mixing biodiesel with diesel fuel. The biodiesel used to produce the mixture met ASTM D6751 and met EPA's registration requirements for fuels and fuel additives. 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 has attached the Certificate for Biodiesel and, if applicable, the Statement of Biodiesel Reseller. Renewable diesel mixtures. Claimant produced a mixture by mixing renewable diesel with liquid fuel (other than renewable diesel). 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 has attached the Certificate for Biodiesel and, if applicable, the Statement of Biodiesel Reseller, both of which have been edited as discussed in the Instructions for Form 4136. See the instructions for line 10 for infommtion about renewable diesel used in aviation. 04 Rate (e) Gallons of (d) Amount of credit (e) CRN blodlesel or renewable diesel a Biodiesel (other than agri-biodiesel) mixtures $1.00 388 b Agri-biodiesel mixtures $1.00 390 c Renewable diesel mixtures $1.00 307 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 (2) Rate (c) Gallons, (d) Amount of credit (e) CRN or gasoline or diesel gallon equivalents a Liquefied petroleum gas (LPG) (see Instructions) $ 419 b "P Series" fuels 420 c Compressed natural gas (CNG) (see instructions) 421 d Liquefied hydrogen 422 e Fischer-Tropsch process liquid fuel from coal (including peat) 423 f Liquid fuel derived from biomass 424 g Liquefied natural gas (LNG) (see instructions) 425 h Liquefied gas derived from biomass 435 ix Anemanve rue. '.wean negunrauon rio. r 06 Rate (c) Gallons, (d) Amount of credit (e) CRN or gasoline or diesel gallon equivalents a Liquefied petroleum gas (LPG) (see instructions) 950 $ 426 b "P Series" fuels .50 427 C Compressed natural gas (CNG) (see instructions) .50 428 d Liquefied hydrogen .50 429 e Fischer-Tropsch process liquid fuel from coal (including peat) .50 430 f Liquid fuel derived from biomass .50 431 g Liquefied natural gas (LNG) (see instructions) .50 432 h Liquefied gas derived from biomass .50 436 I Compressed gas derived from biomass .50 437 Form 4136 (2017) EFTA01222688 Form 4136(2017) Page 4 13 Registered Credit Card issuers Registration No. ► (12) Rate (e) Gallons (d) Amount of credit (e) CRN a Diesel fuel sold for the exclusive use of a state or local government $ .243 $ 380 b Kerosene sold for the exclusive use of a state or local government .243 346 c Kerosene for use in aviation sold for the exclusive use of a state or local government taxed at $.219 369 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) Rata (e) Gallons (d) Amount of credit (e) CRN a Nontaxable use 309 b Ex d .198 306 15 Diesel-Water Fuel Emulsion Blending Registration No. ► (b) Rata (e) Gallons (d) Amount of credit (e) CRN Blender credit $ .046 310 16 Exported Dyed Fuels and Exported Gasoline Blendstocks (b) Rate (e) Gallons (d) Amount of credit (e) CRN a Exported dyed diesel fuel and exported gasoline blendstocks taxed at $.001 $ .001 415 b Exported dyed kerosene .001 416 17 Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and on Form 1040, line 72; Form 1120, Schedule J, line 19b; Form 1120S, line 23c; Form 1041, line 24g; or the proper line of other returns. ► 17 Form 413612o17) EFTA01222689