Form 11 - Nebraska Application For Permission To File A Monthly Combined Sales And Use Tax Or A Combined Annual Litter Fee Return
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1Nebraska Application
Nebraska Application
Nebraska Application
Nebraska Application
Nebraska Application
FORM
FORM
FORM
FORM
FORM
for Permission to File a Monthly Combined Sales and Use Tax
for Permission to File a Monthly Combined Sales and Use Tax
for Permission to File a Monthly Combined Sales and Use Tax
for Permission to File a Monthly Combined Sales and Use Tax
for Permission to File a Monthly Combined Sales and Use Tax
11 11
11 11
or a Combined Annual Litter Fee Return
or a Combined Annual Litter Fee Return
or a Combined Annual Litter Fee Return
11
or a Combined Annual Litter Fee Return
or a Combined Annual Litter Fee Return
• Read instructions on reverse side
• Read instructions on reverse side
• Read instructions on reverse side
• Read instructions on reverse side
• Read instructions on reverse side
PLEASE NO NOT WRITE IN THIS SPACE
nebraska
department
of revenue
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
Name
Name
Street or Other Mailing Address
Street Address
State
Zip Code
City
State
Zip Code
City
1 1 1 1 1 Federal Employer I.D. or Social Security Number
2 2 2 2 2 For Department Use Only
3 3 3 3 3 Indicate program to be covered by this application
4 4 4 4 4 Type of Application
Original
Sales and Use Tax
Litter Fee
Add Location(s) to the Combined Return
5 5 5 5 5 Name and Title of Authorized Representative to Contact Concerning Combined Return
Name
Title
Date
Telephone Number
(
)
6 6 6 6 6 Location of Records
(1)
Same as Location Address
(3)
Other, Identify
(2)
Same as Mailing Address
Address
City
State
Zip Code
7 7 7 7 7 Enter Business Locations which will be Reported on the Combined Return
Business Name, Address, City, State and Zip Code
Nebraska I.D. Number
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.
sign
sign
sign
sign
sign
(
)
here
here
here
here
here
Signature of Owner, Partner, Corporate Officer, or
Title
Date
Telephone Number
Duly Authorized Individual
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
YOUR COMBINED NEBRASKA SALES AND USE TAX
OR LITTER FEE I.D. NUMBER IS:
APPROVED
DISAPPROVED
Date
Authorized Signature
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE – White and Canary Copies
TAXPAYER – Pink Copy
6-026-67 Rev. 9-95 Supersedes 6-026-67 Rev. 10-94
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