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Get and Sign Form 4136
Claimant has not waived the right to make the claim.
For claims on lines 1c and 2b (type of use 13 or 14), claimant certifies that a certificate has not been provided to the
credit card issuer.
1
Note: CRN is credit reference number.
Nontaxable Use of Gasoline
(a) Type of use
a
b
c
d
2
Off-highway business use
Use on a farm for farming purposes
(b) Rate
(c) Gallons
}
$ .183
.183
Other nontaxable use (see Caution above line 1)
Exported
(d) Amount of credit
.183
.184
(e)...
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