Form 24a - Nebraska Contract Permit Application For Nonresident Contractor

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Nebraska Contract Permit Application

FORM

for Nonresident Contractor

24A

• Read instructions on reverse side

PLEASE DO NOT WRITE IN THIS SPACE

nebraska

department

of revenue

RESET FORM

For Department Use Only

Project Name

Project Location

CONTRACTOR’S NAME AND MAILING ADDRESS

PROJECT OWNER’S NAME AND MAILING ADDRESS

Name Doing Business As (DBA)

Project Owner’s Name

Legal Name

Street or Other Mailing Address

City

State

Zip Code

City

State

Zip Code

Nebraska Registration Number

Federal Employer Identiﬁcation Number

FOR DEPARTMENT USE ONLY

32-

Dept. of Roads

Nebraska County Where Project is Located

Construction Start Date (mo/day/yr)

Estimated Completion Date (mo/day/yr)

Multi-project –TCP

Single project bond

Type of Construction

amount

Other

Location of Contract Records for Audit Purposes

Street Address

City

State

Zip Code

Area Code & Telephone Number

1 Is your company (check appropriate box):

The Prime or General Contractor?

A Nonresident Subcontractor?

2 If your company is the nonresident subcontractor making application for a contract permit, identify the prime or general contractor:

Name

Address

City

State

Zip Code

Area Code & Telephone Number(s)

3 Your total contract amount ....................................................................................................................................... 3 $

4 Identify below for this project each:

• Nebraska resident subcontractor awarded a contract,

• Registered and bonded nonresident subcontractor awarded a contract, and

• Contract for less than $2,500.

Also, attach a list of nonresident subcontractors awarded a contract that are not yet registered and bonded with Nebraska.

Name, Address, City, State, Zip Code, AND Telephone Number (Print Legibly)

Contract Price Awarded

Nebraska I.D. Number

List additional entries on an attached sheet of paper.

5 Total contract amounts from line 4........................................................................................................................... 5 $

6 Total amount for calculation of bond (line 3 minus line 5). Complete Nebraska Tax Bond, Form 24B................. 6

7 Estimated cost of ALL construction materials purchased for this project ................................................................ 7

8 Estimated cost of these construction materials which will be purchased in Nebraska for this project..................... 8

9 Approximate labor cost subject to Nebraska withholding.

(See instructions. You are required to withhold and

................................ 9

remit Nebraska income tax on all wages paid to all employees for work performed in Nebraska)

10 Will you bring any employees who are not residents of Nebraska into this state for this project?

YES

If Yes, how many?

11 Will you be hiring any employees who are residents of Nebraska for this contract?

YES

NO If Yes, how many?

12 Approximate value of company equipment (trucks, graders, earthmovers, etc.) to be brought into Nebraska

for this construction project...................................................................................................................................... 12 $

13 Has this equipment (referred to in line 12) been assessed for property tax purposes in another state?

YES

If Yes, submit a notarized copy of assessment with this application.

sign

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.

(

)

here

Authorized Signature

Title

Date

Telephone