OMB No.1545-0162 Fom 4136 Oepartrrent of the Treasury Internal Revenue Service MS) Name (as shown on your income tax ream) Credit for Federal Tax Paid on Fuels ► Go to wwwirs.gov/Fom14136 for instructions and the latest Information. 2018 Attachment Sequence No.23 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 Off-highway business use (a) Type of use (b) Rate (e) Gallons (d) Amount of credit (e) CRN $ .183 $ 362 b Use on a farm for farming purposes .183 } c Other nontaxable use (see Caution above line 1) .183 d Exported .184 411 2 Nontaxable Use of Aviation Gasoline a Use in commercial aviation (other than foreign trade) (a) Type of use (b) Rate (e) Gallons (d) Amount of credit (e) CRN $ .15 $ 354 b Other nontaxable use (see Caution above line 1) .193 324 c Exported .194 412 d WST 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 II. a Nontaxable use (a) Type of use (b) Rate (e) Gallons (d) Amount of credit (e) CRN $ .243 b Use on a farm for farming purposes .243 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 So 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 1219 (a) Type of use For Paperwork Reduction Act Notice, see the separate instructions. 04 Rate (e) Gallons (d) Amount of credit (e) CRN $ .243 348 .243 .17 347 .244 414 .043 377 .218 369 Form 4136 (2018) EFTA01222690 Form 4136 (2018) Page 2 5 Kerosene Used in Aviation (see Caution above line 1) a Kerosene used In commercial aviation (other than foreign trade) taxed at $.244 (a) Type of use (b) Rate (e) Gallons (d) Amount of credit (e) CRN $ .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 boa] 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. Ilt 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 a Use by a state or local govemment (b) Rate (c) Gallons (d) Amount of credit (e) CRN $ .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. Plo. 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 a Use by a state or local govemment (b) Rate (c) Gallons (d) Amount of credit (e) CRN $ .243 1$ 346 b Sales from a blocked pump .243 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 Use In commercial aviation (other than foreign trade) taxed at $219 (a) Type of use (b) Rate (e) Gallons (d) Amount of credit (e) CRN $ .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 (2018) EFTA01222691 Foim 4136(2018) Page 3 9 Reserved for future use Registration No. ► a Reserved for future use b Reserved for future use 10 Reserved for future use (to Rate (c) Gallons of (d) Amount of credit CRN alcohol ler I fs Registration No. ► a Reserved for future use OS Rate (c) Gallons of blodlesel or renewable diesel (d) Amount of credit (e) CRN $ b Reserved for future use c Reserved for future use a 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 Liquefied petroleum gas (LPG) (see Instructions) (a) Type of use dd Rate (c) Gallons, or gasoline or diesel gallon equivalents (d) Amount of credit (e) CRN $ 419 420 b -9 Series" fuels c Compressed natural gas (CNG) (see instructions) 421 d Liquefied hydrogen 422 e Flscher•Tropsch process liquid fuel from coal Oncluding peat) 423 424 f Liquid fuel derived from biomass g Uquefied natural gas (LNG) (see instructions) 425 435 h Uquefied gas derived from biomass • (b) Rate (c) Gallons, or gasoline or diesel gallon equivalents (d) Amount of credit (e) CRN a Reserved for future use ■ b Reserved for future use c Reserved for future use d Reserved for future use e Reserved for future use f Reserved for future use g Reserved for future use h Reserved for future use I Reserved for future use Fon 4136 izolal EFTA01222692 Form 4136(2018) Page 4 13 Registered Credit Card Issuers Registration No. 19. a Diesel fuel sold for the exclusive use of a state or local government 00 Rafe (e) Gallons (d) Amount of credit (e) CRN $ .243 360 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 t219 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 e of use see instructions). a Nontaxable use (a) Type of use (b) Rats (e) Gallons (d) Amount of credit (e) CRN $ 309 b Exported .198 306 15 Diesel-Water Fuel Emulsion Blending Blender credit Registration No. ► (b) Rata (e) Gallons (d) Amount of credit (e) CRN $ .046 16 Exported Dyed Fuels and Exported Gasoline Blendstocks a b Exported dyed diesel fuel and exported gasoline blendstocks taxed at $.001 (al Rata (e) Gallons (d) Amount of credit $ .001 Exported dyed kerosene .001 310 (e) CRN 415 416 17 Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and on Schedule 5 (Form 1040), line 73; Form 1120, Schedule J, line 20b; Form 1120S, line 23c; Form 1041, line 25h; or the proper line of other returns. ► 17 $ • Form 4136 (2018) EFTA01222693