Form 21mf - Motor Fuels Application For Abatement Of Penalty printable pdf download

Form 21mf - Motor Fuels Application For Abatement Of Penalty

Motor Fuels Application for

FORM

21MF

Abatement of Penalty

nebraska

PLEASE DO NOT WRITE IN THIS SPACE

department

of revenue

Nebraska Identification Number as it Appears on Your Report or Return

Federal Employer Identification or Social Security Number

Tax Period for Which Penalty Was Assessed

NAME AND LOCATION ADDRESS

NAME AND MAILING ADDRESS

Name

Street Address

Street or Other Mailing Address

City

State

Zip Code

City

State

Zip Code

Tax Program for Which Penalty Was Assessed (Check only one):

Complete a separate application for each tax program.

Motor Vehicle/Diesel Fuels

Motor Fuels Carrier

Petroleum Release Remedial Action Fee

Motor Fuels Terminal Operator

Aircraft Fuels

Consumer’s Use

Compressed Fuel

Other_______________________

Amount of Penalty

Note: Do not include interest. A request for abatement of penalty

will not be considered until the tax and interest have been paid.

I declare that my failure to comply with the provisions of the Nebraska Motor Fuels Tax Laws and Regulations was

not due to negligence or intentional disregard of the Laws and Regulations, but from the following causes which I submit

were beyond my reasonable control (attach a separate sheet if more space is needed):

Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.

sign

here

Authorized Signature

Signature of Preparer Other Than Taxpayer

Title

Date

Address

Date

FOR MOTOR FUELS DIVISION USE ONLY

Penalty Assessed

$ _______________

COMMENTS:

Penalty Abated

$ _______________

Remaining Penalty

$ _______________

Due and Payable

Authorized Signature

Date

Mail this application to: MOTOR FUELS DIVISION, P.O. BOX 98904, LINCOLN, NE 68509-8904

MOTOR FUELS DIVISION – White and Yellow Copies

TAXPAYER Retain Pink Copy

5-2002

3-439-1994 Rev.

Supersedes 3-439-1994 Rev. 3-1998

Form 21mf - Motor Fuels Application For Abatement Of Penalty

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