Form 8453n - Nebraska Individual Income Tax Declaration For Electronic Filing - 2000
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2NEBRASKA INDIVIDUAL INCOME TAX
FORM 8453N
DECLARATION FOR ELECTRONIC FILING
ne
2000
dep
for Tax Year Beginning January 1 and Ending December 31, 2000
of
• Read instructions on reverse side
nebraska
PLEASE DO NOT WRITE IN THIS SPACE
department
of revenue
IRS Declaration Control Number (DCN)
–
–
–
0
0
1
First Name(s) and Initial(s)
Last Name
Social Security Number
Spouse’s Social Security Number
Home Address (Number and Street or Rural Route and Box Number)
High School District Code
City, Town, or Post Office
State
Zip Code
PART I – TAX RETURN INFORMATION (Whole Dollars Only)
1 Total federal adjusted gross income (AGI) (line 19, Form 1040A; or line 4, Form 1040EZ;
$
or line 33, Form 1040) ............................................................................................................. 1
S
2 Total Nebraska tax (line 17, Form 1040N; or line 7, Form 1040NS) ........................................ 2
3 Nebraska income tax withheld (line 28, Form 1040N; or line 10, Form 1040NS) (attach state
T
copy of 2000 Forms W-2, W-2G, 1099-R, or 1099-MISC) ....................................................... 3
$
A
4 Refund (line 38, Form 1040N; or line 15, Form 1040NS) ........................................................ 4
$
T
5 Amount you owe (line 33, Form 1040N or line 11, Form 1040NS) .......................................... 5
If I have filed a balance due return, I understand that if for any reason my direct debit is canceled,
E
whether due to my request to cancel or errors on my return, that my payment is still due on or before
April 16, 2001, and I remain liable for my tax liability and all applicable interest and penalties.
PART II – DIRECT DEPOSIT OF REFUND OR DIRECT DEBIT FOR BALANCE DUE
O
6 Type of Transaction
F
I agree to have my income tax refund directly deposited into the designated account by the Nebraska Department of Revenue and its
designated financial institution as specified in my 2000 Nebraska individual income tax return. If I have filed a joint return, this is an
irrevocable appointment of my spouse as an agent to receive the refund.
N
I authorize the Nebraska Department of Revenue and its designated financial institution to initiate an automatic withdrawal (direct debit)
to my account as specified in my 2000 Nebraska individual income tax return. I understand that to cancel this automatic withdrawal, I
E
must notify a department representative no later than two (2) business days prior to the Debit Date I have specified. I also authorize the
financial institutions involved in the processing of my payment to receive confidential information necessary to answer inquiries and
resolve problems where possible.
B
9 Name of Financial Institution and, if Applicable, Branch Name
7 Debit Date
8
Debit Amount
R
$
10 Routing Transit Number (RTN)
A
The first two numbers of the RTN must be 01 through
12 or 21 through 32.
S
11 Depositor Account Number (DAN)
12 Type of Account
K
Savings
Checking
A
I declare, under penalties of perjury, that I have compared the information on my return with the information I have provided to my electronic return
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originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my 2000 Nebraska Individual
A
Income Tax Return. If I have filed federal and state returns and there is an error on my state return, I understand my federal return will be rejected.
X
To the best of my knowledge and belief, my return is true, correct, and complete. I consent to having my return, including this declaration and
accompanying schedules and statements, sent to the Internal Revenue Service.
P
sign
A
(
)
Y
here
Taxpayer’s Signature
Telephone Number
Date
E
If you are also the Electronic Return Originator (ERO) and
R
Spouse’s Signature (If filing jointly, both must sign)
are preparing your own return, check this block
and
mail the original of this form to the Nebraska Department
of Revenue and keep a copy for your records.
Be sure to attach state copies of all documents substantiating withholding and retain for 3 years after the due date.
Have questions? Check our Web site: or call 1-800-742-7474 (in Lincoln, call 471-5729).
8-523-2000
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