Form Ia 4136 - Iowa Fuel Tax Credit - 2015
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3Iowa Department of Revenue
https://tax.iowa.gov
2015 IA 4 136
Iowa Fuel Tax Credit
Name(s)
SSN or FEIN
Pass-Through Entity (if applicable) ___________________________________________________________
Pass-Through FEIN __________________________________ Tax Period Ending Date
Check appropriate box(es):
1) Farming
2) Commercial
3) Commercial Fishing
4) Other
Fuel used for:
(specify)
1. Gasoline
Invoice
Invoice
Highway
Tax
Fuel Tax
Fuel Tax
Claimed
Sales
Date
Gallons
Gallons
Rate
Paid
Credit
Gallons
Tax
01/01/2015
to
1a.
$0.21
$
$
$
02/28/2015
03/01/2015
to
1b.
$0.31
$
$
$
06/30/2015
07/01/2015
to end of
1c.
$0.308
$
$
$
tax year
2. Ethanol - Blended Gasoline
Invoice
Highway
Tax
Fuel Tax
Fuel Tax
Invoice
Claimed
Sales
Gallons
Gallons
Rate
Paid
Credit
Date
Gallons
Tax
01/01/2015
to
2a.
$0.19
$
$
$
02/28/2015
03/01/2015
to
2b.
$0.29
$
$
$
06/30/2015
07/01/2015
to end of
2c.
$0.293
$
$
$
tax year
3. Undyed Diesel Fuel - B0 to B10
Invoice
Invoice
Highway
Tax
Fuel Tax
Fuel Tax
Claimed
Sales
Date
Gallons
Gallons
Rate
Paid
Credit
Gallons
Tax
01/01/2015
3a.
to
$0.225
$
$
$
02/28/2015
03/01/2015
to end of
3b.
$0.325
$
$
$
tax year
41-036a (09/11/15)
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