Nebraska Tobacco Products Tax Return
FORM
for Products Other than Cigarettes
56
• Attach Nebraska Schedule I, Form 56
• Read instructions on reverse side
PLEASE DO NOT WRITE IN THIS SPACE
Nebraska Identification Number
Tax Period
RESET FORM
Check this box if you have discontinued importing or manufacturing tobacco products.
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
1 Total amount of tobacco products imported this month (other than cigarettes) plus the total amount
$ $
of tobacco products manufactured and sold in Nebraska this month (Nebraska Schedule I, line 1)
1
2 Total amount of tobacco products (other than cigarettes) exported
to other states (Nebraska Schedule I, line 2) ................................................ 2
3 Total amount of tobacco products (other than cigarettes) sold
to the U.S. government or its agencies.......................................................... 3
4 Total exempt amount (line 2 plus line 3) ............................................................................................... 4
5 Total amount subject to tax (line 1 minus line 4) .................................................................................. 5
6 Total tobacco products tax (line 5 multiplied by
) .................................................................. 6
.20
7 Collection fee (line 6 multiplied by .025; if the result is $75.00 or more, enter $75.00) ........................ 7
8 Tobacco products tax due (line 6 minus line 7) .................................................................................... 8
9 Credit (credit memorandum must be attached, refer to instructions) ................................................... 9
10 Total tobacco products tax due (line 8 minus line 9) ............................................................................10
11 Previous balance with applicable interest at
11
% per year and payments received through
$ $
12 BALANCE DUE (line 10 plus line 11). Pay in full with return................................................................12
Under penalties of law, I declare that I have examined this return, including accompanying schedules, and to the best of my
knowledge and belief, it is correct and complete.
sign
(
)
(
)
here
Authorized Signature
Authorized Signature
Authorized Signature
Authorized Signature
Telephone Number
Telephone Number
Telephone Number
Telephone Number
Signature of Preparer Other than Taxpayer
Signature of Preparer Other than Taxpayer
Signature of Preparer Other than Taxpayer
Signature of Preparer Other than Taxpayer
Telephone Number
Telephone Number
Telephone Number
Telephone Number
Title
Date
Address
Date
for the Directory of Certified Tobacco Product Manufacturers and Brands that are
Check our Web site:
Check our Web site:
Check
approved for sale in Nebraska. If you have questions, call 1-800-742-7474 (toll free in NE and IA) or 1-402-471-5729.
THIS RETURN IS DUE ON OR BEFORE THE 10TH DAY OF THE MONTH FOLLOWING THE TAX PERIOD INDICATED ABOVE
Mail this return and payment to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
8-2007
PLEASE MAKE A COPY TO KEEP WITH YOUR RECORDS
5-175-1987 Rev.
Supersedes 5-175-1987 Rev. 11-2006