Form 7-I - Economic Incentive Claim For Refund Of Sales And Use Tax
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1Economic Incentive Claim for Refund
FORM
of Sales and Use Tax
7–I
• Attach supporting documents
• Read instructions on reverse side
PLEASE DO NOT WRITE IN THIS SPACE
Nebraska Identification Number
Federal Employer I.D. or Social Security Number
RESET FORM
NAME AND LOCATION ADDRESS OF CLAIMANT
NAME AND MAILING ADDRESS OF CLAIMANT (If different from location)
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
PROVIDE BASIS FOR CLAIM — ATTACH APPROPRIATE
Claim Period
Beginning
,
and Ending
,
DOCUMENTATION AND SEE INSTRUCTIONS
AMOUNT CLAIMED
1 Amount of Nebraska sales and
use tax overpayment .............
1
LB 775
Credit Refund
Credit Refund
Credit Refund
Credit Refund
2 Local (city) sales or use tax:
Local (city) sales or use tax:
Local (city) sales or use tax:
Local (city) sales or use tax:
Direct Refund
Direct Refund
Direct Refund
Direct Refund
LB 312
City Name
Amount of Tax
Aircraft
Aircraft
Aircraft
Aircraft
Project No.
LB 270
3 Total of local sales or use tax
LB 608
3
(total of line 2). . . . . . . . . . . . .
4 Total Nebraska and local sales
or use tax (total of lines 1 & 3)
4
5 Can the Department of Revenue contact you or send you information on this claim via e-mail or FAX?
an the Department of Revenue contact you or send you information on this claim via e-mail or FAX?
an the Department of Revenue contact you or send you information on this claim via e-mail or FAX?
YES
YES
YES
NO
NO
NO
E-mail Address
FAX #
(
)
6 Print the name of the individual the Department may contact to obtain additional information regarding this claim:
(
)
Authorized Contact Person (Please Print)
Telephone Number
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.
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.
sign
(
)
(
)
here
Authorized Signature (Owner, Partner, Corporate Officer)
Telephone Number
Signature of Preparer Other Than Taxpayer
Signature of Preparer Other Than Taxpayer
Telephone Number
Title (See Instructions)
Date
Address
Date
ACTION TAKEN BY THE NEBRASKA DEPARTMENT OF REVENUE
CAUTION: Any LB 312 city sales tax refund that exceeds $25,000 will be
ACH ON FILE
APPROVED
refunded in accordance with the statute and agreement. Those marked with
YES
YES
YES
NO
NO
NO
a “D” in the code section to the left are delayed refund amounts. See
1
instructions on the back.
STORAGE
Amount
Code
2
Current refund amount to be issued ________________________
BOX __________________
Total delayed refund amounts
________________________
Total refund amount
________________________
REF. TYPE_____________
COMMENTS:
FORCE CODE__________
3
DATE TO
FINANCE______________
Total
4
APPROVED, ISSUE REFUND
APPROVED AS REVISED,
SEE COMMENTS OR LETTER/E-MAIL DATED ___________________
Your refund, except for delayed refund amounts, will be issued in four to six weeks after approval.
DISAPPROVED, SEE COMMENTS OR LETTER DATED __________________
Authorized Signature
Date
Mail this claim and supporting documentation to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 98903, LINCOLN, NE 68509-8903
Please make a copy of this form for your records
6-392-2003 Rev. 4-2008
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