Form 20 - Nebraska Tax Application Page 2
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1
2Read the attached Nebraska Licensing Requirements to know all the tax programs that you are required to be licensed for.
If you need to report a liability for periods prior to the date of this application, enter the earliest date (month, day, year) for which you need a return.
Check Type of Program(s) Being Applied For:
13 SALES AND USE TAX
MO
DAY
YEAR
Sales Tax Permit — Enter date of first sale .................................................................................................................
a. Select a filing frequency based on your estimated annual taxable sales:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
b. If you have more than one licensed location, will your returns be filed:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
Separate for each location
Separate for each location
Separate for each location
Separate for each location
Separate for each location
Separate for each location
Separate for each location
(2)
(2)
(2)
(2)
(2)
(2)
(2)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
Combined for all locations (File application, Form 11)
MO
DAY
YEAR
Consumer’s Use Tax — Enter date of first transaction
Consumer’s Use Tax — Enter date of first transaction
Consumer’s Use Tax — Enter date of first transaction
Consumer’s Use Tax — Enter date of first transaction................................................................................................
a. Do not check this block if a sales tax permit has been applied for.
b. Select a filing frequency based on your estimated annual taxable purchases:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
More than $60,000 (monthly)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
$18,000 to $60,000 (quarterly)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
Less than $18,000 (annual)
14 INCOME TAX
MO
DAY
YEAR
Income Tax Withholding — Enter date of first wages paid
Income Tax Withholding — Enter date of first wages paid
Income Tax Withholding — Enter date of first wages paid
Income Tax Withholding — Enter date of first wages paid ..........................................................................................
a. Will your average Nebraska monthly withholding exceed $500?............................. (1)
(1)
(1)
(1)
(1)
(1)
(1)
YES
YES
YES
YES
YES
YES
YES
(2)
(2)
(2)
(2)
(2)
(2)
(2)
NO
NO
NO
NO
NO
NO
NO
b. Will your annual state income tax withholding be less than $500 per year?........... (2)
(2)
(2)
(2)
(2)
(2)
(2)
YES
YES
YES
YES
YES
YES
YES
(4)
(4)
(4)
(4)
(4)
(4)
(4)
NO
NO
NO
NO
NO
NO
NO
If you answer yes, mark filing frequency preference............................................... (2)
(2)
(2)
(2)
(2)
(2)
(2)
Quarterly (4)
Quarterly (4)
Quarterly (4)
Quarterly (4)
Quarterly (4)
Quarterly (4)
Quarterly (4)
Annually
Annually
Annually
Annually
Annually
Annually
Annually
c. Will your withholding tax returns be filed:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
For each separate location
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
Consolidated for all locations
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
Consolidated by region or district
d. If you will have a payroll service prepare your returns, attach a power of attorney containing original signatures.
e. Additional Business Operations Employing Nebraska Residents (Attach Additional Sheet if Necessary)
Nebraska I.D. Number
Nebraska I.D. Number
Nebraska I.D. Number
Nebraska I.D. Number
Nebraska I.D. Number
Nebraska I.D. Number
Business Name
Business Name
Business Name
Business Name
Business Name
Business Name
Location Address, City, State, Zip Code
Location Address, City, State, Zip Code
Location Address, City, State, Zip Code
Location Address, City, State, Zip Code
Location Address, City, State, Zip Code
Location Address, City, State, Zip Code
(Enter Beginning Date)
MO
DAY
YEAR
Corporate Income Tax
Corporate Income Tax
Corporate Income Tax
Corporate Income Tax.................................................................................................................................................
Are you an S Corporation? .......................................................................................... (3)
(3)
(3)
(3)
(3)
(3)
(3)
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
Partnership Income Tax
Partnership Income Tax
Partnership Income Tax
Partnership Income Tax ..............................................................................................................................................
Fiduciary Income Tax
Fiduciary Income Tax
Fiduciary Income Tax
Fiduciary Income Tax ..................................................................................................................................................
Financial Institution Tax (indicate type of institution)
Financial Institution Tax (indicate type of institution)
Financial Institution Tax (indicate type of institution)
Financial Institution Tax (indicate type of institution) ...................................................................................................
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
Bank
Bank
Bank
Bank
Bank
Bank
Bank
Bank
Bank
Bank
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
Savings and Loan
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
(3)
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
Credit Union
(4)
(4)
(4)
(4)
Other (specify):
Other (specify):
Other (specify):
Other (specify):
(Enter Date of
First Transaction)
15 MISCELLANEOUS TAXES
MO
DAY
YEAR
Tire Fee Permit
Tire Fee Permit
Tire Fee Permit
Tire Fee Permit ...........................................................................................................................................................
a. Select a filing frequency based on your estimated annual taxable tire sales:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
More than 3,000 (monthly)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
(2)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
900 – 3,000 (quarterly)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Less than 900 (annual)
Lodging Tax Permit
Lodging Tax Permit
Lodging Tax Permit
Lodging Tax Permit .....................................................................................................................................................
a. Select a filing frequency based on your estimated annual taxable sales:
(1)
(1)
(1)
(1)
(1)
(1)
(1)
$10,000 or more (monthly)
$10,000 or more (monthly)
$10,000 or more (monthly)
$10,000 or more (monthly)
$10,000 or more (monthly)
$10,000 or more (monthly)
$10,000 or more (monthly)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
Less than $10,000 (annual)
Less than $10,000 (annual)
Less than $10,000 (annual)
Less than $10,000 (annual)
Less than $10,000 (annual)
Less than $10,000 (annual)
Less than $10,000 (annual)
Litter Fee License
Litter Fee License
Litter Fee License
Litter Fee License .......................................................................................................................................................
a. If you have more than one licensed location, you must file a combined litter fee return. File application, Form 11
MO
DAY
YEAR
Severance and Conservation
Severance and Conservation
Severance and Conservation
Severance and Conservation......................................................................................................................................
Wholesale Cigarette Dealer’s Permit — $500 Fee & $1,000 Bond Required (ENCLOSE PAYMENT & BOND) ....
Wholesale Cigarette Dealer’s Permit —
Wholesale Cigarette Dealer’s Permit —
Wholesale Cigarette Dealer’s Permit —
License to Transport Unstamped Cigarettes — $10 Fee & $1,000 Bond Required (ENCLOSE PAYMENT & BOND)
License to Transport Unstamped Cigarettes —
License to Transport Unstamped Cigarettes —
License to Transport Unstamped Cigarettes —
Tobacco Products License — $25 Fee (ENCLOSE PAYMENT) ................................................................................
Tobacco Products License —
Tobacco Products License —
Tobacco Products License —
You do not need this license if tobacco products (not including cigarettes) are purchased from a supplier who has a Nebraska
tobacco products license.
a. Foreign corporation must attach Nebraska certificate of authority.
b. Noncorporate persons must designate a Nebraska resident agent.
16 Person to contact regarding this application
(
(
(
)
)
)
Name
Title
Telephone 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
(
)
here
Signature of Owner(s), Partner, Member, Corporate Officer,
Title
Date
Telephone Number
Person Authorized by Attached Power of Attorney
If no fees or bonds are required, you may fax this form to (402) 471-5927, OR
MAIL THIS APPLICATION WITH ALL REQUIRED FEES AND BONDS TO:
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 98903, LINCOLN, NE 68509-8903
Visit our Web Site: , or call 1-800-742-7474 (toll free in NE and IA) or 1-402-471-5729.
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