FORM
Application for Abatement of Interest
21A
• Complete separate application for each assessment
PLEASE DO NOT WRITE IN THIS SPACE
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Nebraska Identification Number as it appears
Social Security Number (Individual Income Tax)
on your return
Tax Period for Which Interest Was Assessed
Amount of Interest Assessed
$
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name
Name
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
• A request for abatement of interest will not be considered until the tax has been paid.
Tax Program for Which Interest Was Assessed: (Check one)
Sales or Use Tax
Motor Fuels Tax
Bingo, Lottery, Raffle, or Lottery by Pickle Card
Individual Income Tax
Litter Fee
Mechanical Amusement Device Tax
Corporation Income Tax
Lodging Tax
Cigarette Tax
Fiduciary Income Tax
Tire Fee
Tobacco Products Tax
Withholding Tax
Oil and Gas Severance or
Waste Reduction and Recycling Fee
Partnership Income Tax
Conservation Tax
Other ____________________________________
Interest will be considered for abatement for the following reasons only. Please check the box(es) that apply to you.
Interest was assessed due to an error or unreasonable delay by the Department. (Provide explanation.)
Interest was assessed due to erroneous written advice by the Department when the advice was a direct response to a request from the taxpayer and the
taxpayer reasonably relied upon the advice. (Attach copy of the request and the written advice.)
Interest was attributable to an amount that was previously refunded without payment of interest. Interest can be abated up to the date the previous refund
was issued. (This reason does not apply to Motor Fuels taxes.)
Interest was assessed because of an unrequested amount erroneously refunded to the taxpayer (provided the taxpayer did not request the refund and it was not
caused by information supplied by the taxpayer). Interest may be abated for the first 90 days after the refund was issued.
Interest on a related federal amount was abated by the Internal Revenue Service. (Attach copy of federal document showing abatement.) (This reason
does not apply to Motor Fuel taxes.)
Interest was assessed for taxes where the taxpayer voluntarily complied with the tax laws by filing delinquent tax return(s) for prior period(s). (This reason
does not apply to Motor Fuel taxes.)
Interest was assessed for taxes where a taxpayer was unable to file returns timely because of family illness or death. This could include the discovery after
death of unfiled returns for a deceased taxpayer. (This reason does not apply to Motor Fuel taxes.)
Interest was assessed on taxes which were filed after taxpayer records were destroyed due to natural disaster. (This reason does not apply to Motor Fuel
taxes.)
EXPLANATION:
Under penalties of law, I declare that, as taxpayer or preparer, I have examined this application, and to the best of my knowledge and belief, it is
correct and complete.
sign
here
Signature of Owner, Partner, Member, Corporate Officer, or Person Authorized
Signature of Preparer Other Than Taxpayer
by Attached Power of Attorney
Date
Title
Date
Address
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
Tranaction Code
Amount
$
Interest Assessed
COMMENTS:
$
Interest
Interest Abated
$
Line No. _______
Remaining Interest
Line No. _______
Authorized Signature
Date
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
(When action is completed, a copy will be returned to you.)
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
2-2009
7-201-1991 Rev.
Supersedes 7-201-1991 Rev. 1-1997