Form 7 - Claim For Overpayment Of Sales And Use Tax
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1Claim for Overpayment of Sales and Use Tax
FORM
7
• Attach supporting documents.
• Read instructions on reverse side.
PLEASE DO NOT WRITE IN THIS SPACE
Nebraska Identification Number
Federal Employer ID or Social Security Number
Claim Period
RESET
PRINT
Beginning ______________________ , ________ and Ending ______________________ , ________
NAME AND LOCATION ADDRESS OF CLAIMANT
NAME AND MAILING ADDRESS OF CLAIMANT
Name
Name
Legal Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
AMOUNT CLAIMED
PROVIDE BASIS FOR CLAIM AND ATTACH APPROPRIATE
1 Amount of Nebraska sales and
DOCUMENTATION (See Instructions)
use tax overpayment .............
1
2 Local sales and use tax overpayment:
Local Taxing Jurisdiction
Amount of Local Tax Overpayment
3 Total of line 2. . . . . . . . . . . . . .
3
4 Total of lines 1 and 3 . . . . . . . .
4
5 Select method of payment (Check One):
Issue refund (Your refund will be issued in four to six weeks after approval.)
Establish credit to sales or use tax account (Do not use credit until shown on return.)
6 Name of individual to be contacted regarding this claim:
(
)
Title
E-Mail Address
Daytime Telephone Number
Authorized Contact Person (Please Print)
I declare under penalties of law that I have examined this claim, and to the best of my knowledge and belief, it is correct and complete.
sign
I also declare that payment of this claim has not been previously made by the state, nor have I claimed or received a refund from the retailer.
(
)
(
)
here
Authorized Signature (Owner, Partner, Corporate Officer)
Telephone Number
Signature of Preparer Other Than Taxpayer
Telephone Number
Date
Address
Date
Title (See Instructions)
ACTION TAKEN BY THE NEBRASKA DEPARTMENT OF REVENUE
ACH ON FILE
APPROVED
COMMENTS:
YES
NO
1
Code
Amount
DIRECT VOUCHER
TAX CAT. _________
REF. TYPE____________
FORCE CODE_________
3
DATE TO
FINANCE_____________
Total
4
APPROVED
CREDIT ACCOUNT
ISSUE WARRANT
APPROVED AS REVISED
DISAPPROVED
SEE COMMENTS
SEE COMMENTS
SEE LETTER DATED ___________
SEE LETTER DATED ___________
Authorized Signature
Date
Mail this claim and supporting documentation to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 98903, LINCOLN, NE 68509-8903
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
4-2010
Please make a copy of this form for your records.
6-063-1967 Rev.
Supersedes 6-063-1967 Rev. 2-2009
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