Form 21 - Request For Abatement Of Penalty - Nebraska Department Of Revenue
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Request for Abatement of Penalty
21
Social Security Number (Individual Income Tax)
Nebraska ID Number (as it appears on your return)
PLEASE DO NOT WRITE IN THIS SPACE
RESET FORM
Tax Period for Which Penalty Was Assessed (for income tax, complete a separate request for each
PRINT FORM
penalty)
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name Doing Business As
Name
Legal Name
Street or Other Mailing Address
City
State
Zip Code
Street Address
City
State
Zip Code
Tax Program for Which Penalty Was Assessed (check one). (Complete a separate Form 21 for each tax program.)
Sales or Use Tax
Oil and Gas Severance or Conservation Tax
Cigarette Tax
Fiduciary Income Tax
Withholding Tax
Litter Fee
Bingo, Lottery, Raffle, or Lottery by Pickle Card
Waste Reduction and Recycling Fee
Individual Income Tax
Lodging Tax
County and City Lottery
Other
Corporate Income Tax
Tire Fee
Mechanical Amusement Device Tax
Amount of Penalty
Note: Please do not include requests for abatement of interest or underpayment of estimated tax penalties
(Forms 2210N or 2220N). A request for abatement of penalty will not be considered until the tax and interest
$
have been paid. Complete
Form 21A
to request abatement of interest for specified situations only.
Authorized Contact Person
Title
Daytime Phone
Email Address
I declare that my failure to comply with the provisions of the Nebraska 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 request, and to the best of my knowledge and belief, it is correct and complete.
sign
here
Signature of Owner, Member, Partner, Corporate Officer,
Title
Date
Daytime Phone
or Person Authorized by Attached Power of Attorney
Signature of Preparer Other Than Taxpayer
Title
Date
Daytime Phone
Email Address
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
Tran Code
Amount
$
Penalty Assessed
COMMENTS:
Penalty
$
Penalty Abated
Line # ___
$
Remaining Penalty
Line # ___
Authorized Signature
Date
Mail this request to: NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818.
FAX this request to 402-471-5927.
, 800-742-7474 (NE and IA), or 402-471-5729
12-2011
7-103-1975 Rev.
Supersedes 7-103-1975 Rev. 11-2010
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