Nebraska Tax Amnesty Application
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2Nebraska Tax Amnesty Application
nebraska
ne
department
dep
THE AMNESTY APPLICATION PERIOD IS AUGUST 1, 2004 THROUGH OCTOBER 31, 2004
of revenue
of
PLEASE DO NOT WRITE IN THIS SPACE
MAIL THIS APPLICATION, NO LATER THAN NOV. 1, 2004, TO:
NEBRASKA DEPARTMENT OF REVENUE, TAX AMNESTY
PO BOX 98903
REVERSE SIDE MUST BE
RESET FORM
LINCOLN NE 68509-8903
COMPLETED AND SIGNED
PART I — TAXPAYER INFORMATION
A. FOR INDIVIDUAL INCOME TAX AND MOTOR VEHICLE/MOTOR BOAT SALES TAXES
First Name(s) and Initial(s)
Last Name
Social Security Number
Spouse's Social Security Number
B. FOR BUSINESS TAXES
Business Name (DBA)
Nebraska Identification Number
Federal Identification Number
Legal Name of Business
C. ADDRESS AND CONTACT INFORMATION
Street or Other Mailing Address
Home Telephone Number
City
State
Zip Code
Daytime Telephone Number
E-mail Address
FAX Number
PART II — TAX PROGRAM(S) AMNESTY APPLIED FOR (Check all that apply)
FOR INDIVIDUALS:
Individual Income Tax — Tax Year(s):
Individual Consumer's Use Tax — Tax Year(s):
Motor Vehicle and Motor Boat Sales Tax (complete the following information, and attach listing if necessary):
Year
Make
Vehicle Identification Number (VIN)
Purchase Date
Purchase Price
$
$
$
FOR BUSINESSES:
TAX PERIOD(S)
TAX PERIOD(S)
Month/Year
Month/Year
Month/Year
Month/Year
Tax Type
Tax Type
Beginning
Ending
Beginning
Ending
Sales and Use Tax . . . . . . . . . . . . . . . . . . . .
Tire Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Local Sales and Use Tax . . . . . . . . . . . . . . .
Documentary Stamp Tax . . . . . . . . . . . . . . .
Withholding . . . . . . . . . . . . . . . . . . . . . . . . . .
Marijuana and Controlled Substances Tax .
Corporate Income Tax . . . . . . . . . . . . . . . . .
MOTOR FUELS TAXES:
Fiduciary Income Tax . . . . . . . . . . . . . . . . . .
Motor Fuel (Gas and Diesel) . . . . . . . .
Partnership . . . . . . . . . . . . . . . . . . . . . . . . . .
Consumer's Use for Diesel Fuel . . . . . .
Estate Tax . . . . . . . . . . . . . . . . . . . . . . . . . . .
Petroleum Release Remedial Action Fee
Cigarette Tax . . . . . . . . . . . . . . . . . . . . . . . .
Aircraft Gas and Jet Fuel . . . . . . . . . . .
Tobacco Products Tax . . . . . . . . . . . . . . . . .
Compressed Fuels (Propane & CNG) .
Lodging Tax . . . . . . . . . . . . . . . . . . . . . . . . .
CHARITABLE GAMING:
Litter Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lottery by Pickle Card . . . . . . . . . . . . .
Severance and Conservation Tax . . . . . . . .
Bingo . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fertilizer Fee . . . . . . . . . . . . . . . . . . . . . . . . .
County/City Lottery . . . . . . . . . . . . . . . .
Financial Institutions Tax . . . . . . . . . . . . . . .
Lottery/Raffle . . . . . . . . . . . . . . . . . . . .
Waste Reduction and Recycling Fee . . . . . .
Mechanical Amusement Device Tax . . . . . .
Has the Nebraska Department of Revenue been in contact with you regarding the above tax program(s)?
YES
NO
If Yes, please indicate name of Department of Revenue employee:
Have you previously filed tax returns for any of the tax periods listed above?
YES
NO
If Yes, please explain:
REVERSE SIDE MUST BE COMPLETED AND SIGNED
7-265-2004
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