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Department of the Treasury
Intemal Revenue Service
A D gnged
B Exempt under sectgon
5o1( c ) ( 3 )
D 408(e)
El 220(e)
D 403A
E] 530(3)
D 529(a)

Print
or
-r e
yp

0 '3fgrc)'g';')e;ra'' 355915

F
G

H
I

OMB No 1545-0687

Exempt Organization Business Income Tax Return
(and proxy tax under section 6033(e))
For calendar year 2012 or other tax year beginning
, 2012, and
ending
, 20
> se''7e''aii.i'{'in'si}uctions.

F vrm

Name of organization ( E] Check box if name changed and see instructions)
BRIGHAM YOUNG UNIVERSITY
Number, street, and room or suite no If a P 0 box, see instnictions
c-233 ASB, PO BOX 21128
City or town state and ZIP code
PROV0, UT 84602

Group exemption number (see instructions) P
Check organization type > |:| 501 (c) corporation

Open to Public Inspection for
501(c)(3) Organizations Only
0 (EB|'11n%:g)eee|'sidt:-!J'IslI;::etil:;I
'
37.o21723o
E ""''3*' ""5'55 "1""? dS
(See Instructions)
445100
E
111900

|:| 501 (c) trust

|:] 401(a) trust

[:| Other trust

Describe the organizations primary unrelated business activity > GROCERY 3. RETAi|_ sA|_i-gs, i=ARiviiN(;
Yes [I No
During the tax year, was the corporation a subsidiary in an affiliated group or a parent-subsidiary controlled group? . . D
If "Yes," enter the name and identifying number of the parent corporation. D The church of Jesus Christ of Latter-day Saints 23-7300405
801-422-8098
The books are in care of > BRIGHAM YOUNG UNIVERSITY
Telephone number >
Unrelated Trade or Business Income
(Al Income
(Bl Expenses
(0) Net

J

1a
b

Gross receipts or sales
Less returns and allowances

1c

7,920,293

2

Cost of goods sold (Sched>ule.A,-line 7) .

.

.

.

.

.

.

2

4,158,651

5;? 3

Gross profit. Subtiqt line2(from line 1c .

.

.

.

.

.

.

3

3,761,642

3,761,642

(40,603)

(40,603)

3
(N
N
>

8,070,923
150,630

c

Balance >

4a
b
c
5

Capital gain net;in Schedule D) . . . . .
Net gaii1_(l<_)'s)(Eer
97, Part\Il'{ lihe 17) (attach Form 4797
Capitalloss deduction f[lQt\"L)lStS\|.( .
.
Income (|oss')~'from paitnerships andS corporations (attach statement)

g
\
(Q
2

6
7
8

Rent inqomg (Sc_hgdele=)' e . .
. . .
UnreIate'd'dbt-finan_<':"\i:i,income_($chedu|e E) . .
Interest, annuities,/royalties, and rents from
organizations (Schedule F) . . . . . . . .

:/3
Q
W

9

. .
controlled
. . .

4a
4b
4c
5
6
7
3

Investment income of a section 501(c)(7), (9), or (17)
organization (Schedule G)
.
. . . . .
9
10
Exploited exempt activity income (Schedule I)
10
11
Advertising income (Schedule J)
11
341,733
401,082
(59,349)
12
Other income (see instructions; attach statement).
12
13
Total. Combine lines 3 through 12
. . . .
13
4,062,772
401,082
3,661,690
Part II Deductions Not Taken Elsewhere (see instructions for limitations on deductions) (except for contributions,
deductions must be directly connected with the unrelated business income)
14
15
16
17

Compensation of officers, directors, and trustees (Schedule K)
Salaries and wages
Repairs and maintenance
Bad debts
. .

14
15
16
17

2,202,797
100,113

18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34

Interest (attach statement)
Taxes and licenses .
. . . . . . . . . . . .
Charitable contributions (see instructions for limitation rules) .
. .
. . . .
Depreciation (attach Form 4562)
. . . . . . . . . . .
21
122,393
Less depreciation claimed on Schedule A and elsewhere on return .
22a
Depletion. . . . . . . . . . . . .
Contributions to deferred compensation plans
Employee benefit programs .
.
Excess exempt expenses (Schedule I)
Excess readership costs (Schedule J)
Other deductions (attach statement) .
Total deductions. Add lines 14 through 28
. . .
. . . . . . . . . . .
Unrelated business taxable income before net operating loss deduction Subtract line 29 from line 13
Net operating loss deduction (limited to the amount on line 30) . .
. . . . . . .
Unrelated business taxable income before specific deduction. Subtract line 31 from line 30 .
Specific deduction (generally $1,000, but see line 33 instructions for exceptions)
. . . . .
Unrelated business taxable income. Subtract line 33 from line 32. If line 33 is greater than line 32,

18
19
20

(50,054

enter the smaller of zero or line 32
For Paperwork Reduction Act Notice, see instructions.

.

.

.
.
.
Cat No 11291J

.

.

.

.

22b
23
24
25
26
27
28
29
30
31
32
33
34

122,398

1,257,644
3,743,005

(81,316)
1,000
(32315)
Form 990-T (2012)

V

Form 990-T (2012)

Page 2

Tax Computation
Organizations taxable as corporations (see Instructions for tax computation) Controlled group
members (sections 1561 and 1563) check here D E] see instructions and;

35
a
b
c
36

Enter your share of the $50,000, $25,000, and $9,925,000 taxable income brackets (in that order):
(1) |$
(2) Is
I
I
(3) |$
Enter organization's share of: (1) Additional 5% tax (not more than $11,750)
$
(2) Additional 3% tax (not more than $100,000) . . . . . . . . .
$
Income tax on the amount on line 34 . . . . . . .
. . . .
. .
. .
D
Trusts taxable at trust rates (see instructions for tax computation). Income tax on
the amount on line 34 from: |:| Tax rate schedule or
Schedule D (Form 1041) . . . . .
D

37
38

Proxy tax (see instructions) .
Alternative minimum tax .

.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.

.

39

Total. Add lines 37 and 38 to line 350 or 36, whichever applies

40a
b
c
d
e
41

Tax and Payments
Foreign tax credit (corporations attach Form 1118; trusts attach Form 1116)
Other credits (see instructions)
. . . . . . . . . .
General business credit. Attach Form 3800 (see instructions) .
Credit for prior year minimum tax (attach Form 8801 or 8827) .
Total credits. Add lines 40a through 40d
Subtract line 40e from line 39
. . . . .
.
.
.

.

.

.

.

.

.

.

.

.

D

35c

o

36
37
38
39

0

.

we
41

0
o

42
43

Other taxes Check If from E] Form 4255 El Form 8611 El Form 8697 El Form 8866 El Other (attach statement)
Total tax. Add lines 41 and 42 .
. . . .
. .
. . . .

42
43

0

44a
b
c
d
e
f
g

Payments: A 2011 overpayment credited to 2012
2012 estimated tax payments
. . .
Tax deposited with Form 8868 . . . .
. . . .
. . . .
Foreign organizations: Tax paid or withheld at source (see instructions)
Backup withholding (see instructions)
. . . . . . . . . . . .
Credit for small employer health insurance premiums (Attach Form 8941) .
Other credits and payments.
El Form 2439

45
46
47

Form 4136
4,397
Other
37
Total > (9
Total payments. Add lines 44a through 44g . . . . . . . . . .
. .
Estimated tax penalty (see instructions). Check If Form 2220 is attached .
Tax due. If line 45 IS less than the total of lines 43 and 46, enter amount owed . .

4,934
. .
. D E]
. .
D

45
46
47

393,015

48
49

Overpayment. If line 45 is larger than the total of lines 43 and 46, enter amount overpaid
. .
D
Enter the amount of line 48 you want Credited to 2013 estimated tax D
1oo_ooo|
Refunded D

48
49

393,015
293,015

40a
40b
40c
40d
.

.

.

.

.

44a
44b
44c
44d
44e
44f

.

146,625
246,456

.

.

Statements Regarding Certain Activities and Other Information (see instructions)
At any time during the 2012 calendar year, did the organization have an interest in or a signature
or other authority over a financial account (bank, securities, or other) in a foreign country?
If Yes," the organization may have to file Form TD F 90-22.1, Report of Foreign Bank and
Financial Accounts. If "Yes," enter the name of the foreign country here D see Attachment No 3

1

2

Yes

N
___

/

During the tax year, did the organization receive a distribution from, or was it the grantor of, or transferor to, a foreign trust? .
If Yes, see instructions for other forms the organization may have to file.

I

3
Enter the amount of tax-exempt interest received or accrued during the tax year D $
2st1ss,493
Schedule ACost of Goods Sold. Enter method of inventory valuation D LowER or cost on MARKET
1
Inventory at beginning of year
1
1,079,413
6
Inventory at end of year .
6
1,102,592
2
Purchases
. . . . . .
2
4,181,825
7
Cost of goods sold. Subtract
3
Cost of labor, . . , _ ,
3
line 6 from line 5. Enter here and
4a
b
5

Additional section 263A costs
In Part I. F19 2 - - - - - 7
4,153,551
(attach Statement) 4a
8
Do the rules of section 263A (with respect to V95 N0
Other costs (attach statement)
4b
property produced or acquired for resale) apply A
*4!
Total. Add |Ines1 through 4b
5
5,251,243
to the organization? . - - - - - I
Under penalties of penury. I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and co plete Declaration of reparer (other than taxpayer) is based on all information 01 which preparer has any knowledge

Here t
MM
Signature of officer
Paid

Pnnt/Type preparer's name

Preparer
use

Date
Preparer's signature

t F
Tme

Ma y the IRS discuss this return
(Z22.L;fnf2?$g"$"'.l.E'L'

Date

Check D If

PTIN

self-employed
FIrrn's name D
Firm's address D

Fim1'sElND
Phone no
Form 990-T (2012)

Form 990-T (2012)

Page 3

Schedule CFlent Income (From Real Property and Personal Property Leased With Real Property)
(see instructions)
1. Description of property
(1)
(2)
(3)
(4)
2. Rent received or accrued
(a) From personal property (if the percentage of rent
for personal property is more than 10% but not
more than 50%)
(1)
(2)
(3)
(4)
Total

3(a) Deductions directly connected with the income
in columns 2(a) and 2(b) (attach statement)

(b) From real and personal property (if the
percentage of rent for personal property exceeds
50% or if the rent IS based on profit or income)

Total

(c) Total income. Add totals of columns 2(a) and 2(b). Enter
P
here and on page 1, Part I. line 6, column (A)
Schedule EUnrelated Debt-Financed Income (see instructions)
2 ' Gross Income from or
1. Description of debt-financed property
allocable to debt-nanced
property

(b) Total deductions.
Enter here and on page 1,
Part I. line 6. column (B) >
3. Deductions directly
with or allocable to
d bt-f connected
ed
e mane property
(a) Straight line depreciation
(b) Other deductions
(attach statement)
(attach statement)

(1)
(2)
(3)
(4)
4. Amount of average
acquisition debt on or
allocable to debt-financed
property (attach statement)

5. Average adjusted basis
of or allocable to
debt-financed property
(attach statement)

1:; dn
b column 5
Y

(1)
(2)
(3)
(4)

7. Gross income reportable
(column 2 x column 6)

(coadlglgogaxbiztjleggggfgns
3(3) and 303

Enter here and on page 1.
Part I, line 7, column (A)

Enter here and on page 1.
Part l, line 7, column (B)

%
%
%
%

Totals
Total dividends-received deductions included in column 8

>
D

Schedule Flnterest, Annuities, Royalties, and Rents From Controlled Organizations (see instructions)
Exempt Controlled Organizations
1. Name of controlled
2. Employer
5. Part of column 4 that is
6. Deductions directly
identification number 3. Net unrelated income 4. Total of specified
organization
connected with income
included in the controlling
(loss) (see instructions)
payments made
in column 5
organization's gross income
(1)
(2)
(3)
(4)
Nonexempt Controlled Organizations
7. Taxable Income

8. Net unrelated income
(loss) (see instructions)

9. Total of specified
payments made

10. Part of column 9 that is
included in the controlling
organization's gross income

11. Deductions directly
connected with income in
column 10

Add columns 5 and 10
Enter here and on page 1.
Part I. line 8, column (A)

Add columns 6 and 11
Enter here and on page 1,
Part I, line 8, column (B)

(1)
(2)
(3)
(4)

Totals

D
Form 990-T (2012)

Form 990-T (2012)

Page 4

Schedule GInvestment Income of a Section 501(c (7), (9), or (17) Organization (see instructions)
3. Deductions
4 Set_as,des
.
1. Description of income
2. Amount of income
directly
connected
(anch
statement)
(attach statement)

5. Total deductions
and set-asides
plus col 4)(col 3

(1)
(2)
(3)
(4)
Enter here and on page 1,
Part I, line 9, column (A).
Totals

Enter here and on page 1,
Part I, line 9, column (B)

D

Schedule lExploited Exempt Activity Income, Other Than Advertising Income (see instructions)
4. Net income
2 Gross
3. Expenses
(loss) from
1. Description of exploited activity

mated
business income
frobmgggor
U

...n;Z.{f..'iwm.
roductlon of
p unrelated
business income

Enter here and on
page 1, Part I,
line 10, col (A)

Enter here and on
page 1, Part I,
line 10, col (B)

E'J;?1f.;(2?f.,"n
2 minus column
3) If a gain,
compute cols 5
through 7

fI;.i";Zf..'..i'h"t
is not unremed
business income

6- Expenses
attributable to
column 5

7. Excess exempt
(co.S:,".?2im..
column 5 hm not
more than
column 4)

(1)
(2)
(3)
(4)

Totals

.

.

Enter here and
on page 1,
Part II, line 26

D

Schedule JAdvertising Income (see instructions)
Part I
Income From Periodicals Reported on a Consolidated Basis
4. Advertising
2. Gross
gain or (loss) (col
1. Name of periodical
advertising
advealggecgosts 2 minus col 3) If
income
9
a gain, compute
cols 5 through 7
(1) BYU Game Day
(2)
(3)
(4)

341,733

5' (E:';u::n

6' RE:::$h'p

7. Excess readership
costs (column 6
minus column 5, but
not more than
column 4)

401,082

Totals (carry to Part ||. line (5))
P
341,733
401,032
(59,349)
Income From Periodicals Reported on a Separate Basis (For each periodical listed in Part II, fill in columns 2
through 7 on a lineby|ine basis.)

1. Name of periodical

2. Gross
advertising
income

adve3r;|3'r:ec(:Ss
9

Enter here and on
page 1, Part I,
line 11, col (A)

Enter here and on
page 1, Part I,
line 11, col (B)

4. Advertising
gain or (loss) (col
2 minus col 3) If
a gain, compute
cols 5 through 7

5' _'.';urLa:n

6' R::::sh'p

7. Excess readership
costs (column 6
minus column 5, but
not more than
column 4)

(1)
(2)
(3)
(4)
Totals from Part I
Enter here and
on page 1,
Part II, line 27

D

Totals, Part II (lines 1-5)

Schedule KCompensation of Officers, Directors, and Trustees (see instructions)
1. Name
(1)
(2)
(3)
(4)
Total. Enter here and on page 1, Part II, line 14

2 1....

4- r'3;$g,:,:gg';,g;,"ngg;ab'e '
%
%
%
%
D
Fomi 990-T (2012)

M4135

Credit for Federal Tax Paid on Fuels

Lgepanmeni oi the Treasury
D lnforrnation about Form 4136 and its instructions is at www.irs.gov/fon-n4136.
Attachment
lntemal Revenue Service (99)
Sequence No
Name (as shown on your income tax return)
Taxpayer identication number
BRIGHAM YOUNG UNIVERSITY
87-0217280
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 1c and 2b (type of use 13 and 14), 3d, 4c, and 5, claimant has not waived the right to make the claim.
For claims on lines 1c and 2b (type of use 13 and 14), claimant certifies that a certificate has not been provided to the
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.
1

Nontaxable Use of Gasoline

Note. CRN is credit reference number.
(a) Type of use

a

Off-highway business use

b
c
d

Use on a farm for farming purposes
Other nontaxable use (see Caution above line 1)
Exported

2

(b) Rate

(c) Gallons

(d) Amount of credit

(e) CRN

5 133
13

183
133
134

25,761

]

$

362

4,897

41 1

Nontaxable Use of Aviation Gasoline
(a) Type of use
a
b
C
d

3

Use in commercial aviation (other than foreign trade)
Other nontaxable use (see Caution above line 1)
Exported
LUST tax on aviation fuels used in foreign trade

(b) Rate

(c) Gallons

$ 15
193
194
001

(d) Amount of credit
$

(e) CRN
354
324
412
433

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 D
D
(a) Type of use (b) Rate
(c) Gallons
(d) Amount of credit (e) CRN
a
b
c
d

Nontaxable
usefor farming purposes
Use
on a farm
Use in trains
Use in certain intercity and local buses (see Caution
above line 1)

e

Exported

4

$ 243
243
.243

] $

360
353

17

350

244

413

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 >
D
(a) Type of use (b) Rate
(c) Gallons
(d) Amount of credit (e) CRN
a
b
c

Nontaxable
at purposes
$.244
Use
on a farmuse
fortaxed
farming
Use in certain intercity and local buses (see Caution
above line 1)

CI
e
f

Exported
Nontaxable use taxed at $ 044
Nontaxable use taxed at $.219

For Paperwork Reduction Act Notice. see the separate instructions.

s ,243
243

} $

346

17

347

244
043
218

414
377
369

Cat No 12625R

Form 4135 (2012)

Form 4136 (2012)
5

Page 2

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

5 200

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

345

d

Nontaxable use (other than use by state or local
government) taxed at $219

213

359

LUST tax on aviation fuels used in foreign trade

001

433

e

6

Sales by Registered Ultimate Vendors of Undyed Diesel Fuel

a
b

7

5

417

Registration No. >

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
.
> E]
(b) Rate
(c) Gallons
(d) Amount of credit (e) CRN
Use by a state or local government
5 24 3
$
350
Use in certain intercity and local buses
17
350

Sales by Registered Ultimate Vendors of Undyed Kerosene (Other
Than Kerosene For Use in Aviation)

Registration No_ 5

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 .
. > E]
(b) Rate
(c) Gallons
(d) Amount of credit (e) CRN
a
b
c

8

Use byfrom
a state
or localpump
government
Sales
a blocked
Use in certain intercity and local buses

$ .243
243
17

sales by Registered Ultimate Vendors of Kerosene For Use in Aviation

} $

346
347

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

a

Use in commercial aviation (other than foreign trade) taxed
at $ 219

s 175

I!
C
d
e

Use in commercial aviation (other than foreign trade) taxed
at $ 244
Nonexempt use in noncommercial aviation
Other nontaxable uses taxed at $ 244
Other nontaxable uses taxed at $ 219

200
025
243
218

f

LUST tax on aviation fuels used in foreign trade

001

(c) Gallons

(d) Amount of credit
$

(e) CRN
355
417
418
346
369

433
Form 41 36 (2012)

Form 4136 (2012)
9

Page 3

Reserved

Registration No. D

(bl Rate
a
b
10

(l Ga""5 '
alcohol

(d) Amount of credit

le) CRN

Reserved
Reserved

.
;

Biodiesel or Renewable Diesel Mixture Credit

Registration No. >

Biodiesel mixtures. Claimant produced a mixture by mixing biodiesel with diesel fuel. The biodiesel used to produce the mixture met ASTM
D6751 and met EPAs 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 EPAs 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 information about renewable diesel used in aviation
('3) Rate

a
b
c
11

Biodiesel (other than agri-biodiesel) mixtures
Agri-biodiesel mixtures
Renewable diesel mixtures

(0) G3"|'|5 0'
biodiesel or
renewable
diesel

$1 00
$1 00
$1 00

(d) Amount of credit

$

(9) CRN

388
390
307

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

$ 183
133

Liquefied petroleum gas (LPG)
P Series fuels

c
d
e

Compressed natural gas (CNG) (GGE = 126 67 cu ft)
Liquefied hydrogen
Fischer-Tropsch process liquid fuel from coal (including
peat)

183
183

421
422

243

423

f
g
h

Liquid fuel derived from biomass
Liqueed natural gas (LNG)
Liqueed gas derived from biomass

243
243
183

424
425
435

Alternative Fuel Credit

$

(e) CRN

a
b

12

419
420

Registration No. >
(bl Rate

E
l

(c) Gallons
(.1) Amount of credit
or gasoline
gallon
equivalents (GGE)

a
b

Liquefied petroleum gas (LPG)
"P Series" fuels

5 50
.50

c
d
e

Compressed natural gas (CNG) (GGE = 121 cu ft)
Liqueed hydrogen
Fischer-Tropsch process liquid fuel from coal (including peat)

.50
50
50

1
g
h
i

Liquid fuel derived from biomass
Liqueed natural gas (LNG)
Liqueed gas derived from biomass
Compressed gas derived from biomass (GGE = 121 cu ft)

50
50
50
50

(cl Gallons
(d) Amount of credit
or gasoline
gallon
equivalents (GGE)
$

(e) CRN

425
427
428
429
430
431
432
436
437
Form 41 36 (2012)

Form 4136 (2012)
13

Page 4

Registered Credit card issuers

Registration No. >
(b) Rate

a
b
c

14

Diesel fuel sold for the exclusive use of a state or local government
Kerosene sold for the exclusive use of a state or local government
Kerosene for use in aviation sold for the exclusive use of a state or local
government taxed at $ 219

(c) Gallons

$ 243
243

(d) Amount of credit
$

(e) CRN
360
346

213

359

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
a

Nontaxable use

b

Exported

15

Diesel-Water Fuel Emulsion Blending

(b) Rate
$ 197

16

306

Registration No. D
(c) Gallons

$ 046

(b) Rate

17

(e) CRN
309

(cl) Amount of credit
$

I

(e) CRN
310

Exported Dyed Fuels and Exported Gasoline Blendstocks

a
b

1

(cl) Amount of credit
$

198

(b) Flate
Blender credit

(c) Gallons

Exported dyed diesel fuel and exported gasoline blendstocks taxed at $ 001
Exported dyed kerosene

(c) Gallons

s 001
001

Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and on Form
1040, line 70, Form 1120, Schedule J, |Ine19b, Fonn 11208, lune 23c, Form 1041, line 24g, or
the proper line of other returns >

(d) Amount of credit
$

17 $

(e) CRN
415
416

4397
Form 4136 (2012)


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