Form 8453n - Nebraska Individual Income Tax Declaration For Electronic Filing - 2006

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NEBRASKA INDIVIDUAL INCOME TAX
FORM 8453N
DECLARATION FOR ELECTRONIC FILING
n e
2006
for Tax Year Beginning January 1 and Ending December 31, 2006
de p
of
• Read instructions on reverse side
nebraska
PLEASE DO NOT WRITE IN THIS SPACE
department
of revenue
IRS Declaration Control Number (DCN)
0
0
7
First Name(s) and Initial(s)
Last Name
Home Address (Number and Street or Rural Route and Box Number)
RESET FORM
Social Security Number
Spouse’s Social Security Number
City, Town, or Post Office
State
Zip Code
PART I –TAX RETURN INFORMATION (Whole Dollars Only)
1 Refund (line 43, Form 1040N; or line 17, Form 1040NS) ......................................................... 1
2 Total amount due (line 38, Form 1040N or line 13, Form 1040NS) .......................................... 2
If I have filed a balance due return, I understand that if for any reason my electronic funds withdrawal is canceled, whether due to my
request to cancel or errors on my return, that my payment is still due on or before April 16, 2007, and I remain liable for my tax liability
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and all applicable interest and penalties.
PART II – DIRECT DEPOSIT OF REFUND OR ELECTRONIC FUNDS WITHDRAWAL FOR BALANCE DUE
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3 Type of Transaction
I agree to have my income tax refund directly deposited into the designated account by the Nebraska Department of Revenue and its designated financial
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institution as specified in my 2006 Nebraska individual income tax return. If I have filed a joint return, this is an irrevocable appointment of my spouse as an
agent to receive the refund.
I authorize the Nebraska Department of Revenue and its designated financial institution to initiate an automatic withdrawal to my account as specified in my
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2006 Nebraska individual income tax return. I understand that to cancel this automatic withdrawal, I must notify a department representative no later than two (2)
business days prior to the Debit Date I have specified. I also authorize the financial institutions involved in the processing of my payment to receive confidential
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information necessary to answer inquiries and resolve problems where possible.
6 Name of Financial Institution and, if Applicable, Branch Name
4 Debit Date
5
Debit Amount
$
7 Routing Transit Number (RTN)
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The first two numbers of the RTN must be 01 through
12 or 21 through 32.
8 Depositor Account Number (DAN)
9 Type of Account
F
Savings
Checking
I declare, under penalties of perjury, that I have compared the information on my return with the information I have provided to my electronic return
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originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my 2006 Nebraska individual
A
income tax return. If I have filed federal and state returns and there is an error on my state return, I understand my federal return may be rejected. I
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understand that my return may be changed if rejected by the state. To the best of my knowledge and belief, my return is true, correct, and complete. I
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consent to having my return, including this declaration and accompanying schedules and statements, sent to the Internal Revenue Service.
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sign
E
(
)
A
here
Y
Taxpayer’s Signature
Telephone Number
Date
B
If you are also the Electronic Return Originator (ERO) and are preparing
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your own return, check this block
and mail the original of this form to
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the Nebraska Department of Revenue and keep a copy for your records.
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Spouse’s Signature (If filing jointly, both must sign)
PART III – DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER
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I declare that I have reviewed the above taxpayer’s return, and that the entries on this form are complete and correct to the best of my knowledge. I
have obtained the taxpayer’s signature on this form and provided the taxpayer with a copy of this form and all forms and information to be filed with the
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Nebraska Department of Revenue. I have followed all other requirements described in Federal Pub. 1345, Handbook for Electronic Filers of Individual
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Income Tax Returns (Tax Year 2006), and any requirements specified by the Nebraska Department of Revenue. If I am also the Paid Preparer, under
penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my
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knowledge and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which preparer has any knowledge.
sign
(
)
A
here
Date
Electronic Return Originator’s Signature
Telephone Number
Check if also Paid Preparer
Check if Self-Employed
Firm’s Name (or yours if self-employed)
Address
City
State
Zip Code
Electronic Filer Identification Number (EFIN)
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Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my
A
knowledge and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any knowledge.
sign
I
(
)
D
here
Paid Preparer’s Signature
Telephone Number
Date
P
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Firm’s Name (or yours if self-employed)
Check if Self-Employed
E
P
Address
City
State
Zip Code
A
ATTENTION ERO’S: DO NOT MAIL THIS FORM TO THE NEBRASKA DEPARTMENT OF REVENUE.
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E
Be sure to attach state copies of all documents substantiating withholding and retain for 3 years after the due date.
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Visit our Web site: , or call 1-800-742-7474 (toll free in NE and IA) or 1-402-471-5729.
8-523-2006

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