Form 54 - Nebraska Tax Application And Return For Mechanical Amusement Device
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1Nebraska Tax Application and Return
FORM
FORM
FORM
FORM
FORM
54
54
54
54
54
for Mechanical Amusement Device
• 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 DO NOT WRITE IN THIS SPACE
PLEASE DO NOT WRITE IN THIS SPACE
PLEASE DO NOT WRITE IN THIS SPACE
PLEASE DO NOT WRITE IN THIS SPACE
PLEASE DO NOT WRITE IN THIS SPACE
nebraska
department
of revenue
1 1 1 1 1 Do you hold, or have you previously held, a Nebraska Identification Number?
YES
NO
If Yes give number
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
NAME AND MAILING ADDRESS
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
2 2 2 2 2 Federal Employer Identification or Social Security Number
3 3 3 3 3 County of Business Location in Nebraska
4 4 4 4 4 For Department Use Only
5 5 5 5 5 Location of Records (1)
Same as Location Address
(3)
Other, Identify:
(2)
Same as Mailing Address
Street Address
State
Zip Code
City
6 6 6 6 6 Reason for Filing Application (1)
Original Application
(2)
Renewal
(3)
Acquired Additional Devices
(4)
Other
7 7 7 7 7 Are you a resident of the State
If not, have you filed an appointment with the Secretary
8 8 8 8 8 Are you a person of good character and reputation
of Nebraska?
of State as agent for the service of summons?
in the community in which you reside?
YES
NO
YES
NO
YES
NO
9 9 9 9 9 Have you been convicted of or pleaded guilty to a felony under the laws
10
10
10
10 Have you been convicted of or pleaded guilty to being the proprietor of a gambling
10
of the State of Nebraska, any other state, or the United States?
house or of any other crime or misdemeanor opposed to decency or morality?
YES
NO
YES
NO
11
11
11
11
11 Accounting Basis (1)
Cash
12
12
12 Accounting Period (1)
Calendar Year — January 1 to December 31
13
13
13
13
13 Date of First Transaction
12
12
(2)
Accrual
(2)
Fiscal Year — 12 Month Basis Ending
(3)
Other
(3)
Fiscal Year — 52 or 53 Week Basis Ending
14
14
14
14
14 Type of Ownership
(1)
Sole Proprietorship
(4)
Domestic Corporation
(7)
Governmental
(10)
Cooperative
(2)
Partnership
(5)
Foreign Corporation
(8)
Fiduciary (Estate or Trust)
(11)
Limited Liability Company
(3)
Nonprofit Corporation
(6)
Domesticated Corporation
(9)
Nonprofit Organization
15
15
15
15
15 Provide a general description of your business operations:
16
16
16
16
16 Identify Owners, Members, Partners, or Corporation Officers (One of the Listed Individuals Must Sign as Applicant)
Social Security Number
Name, Address, City, State, Zip Code
LICENSE FEES AND OCCUPATION TAX
LICENSE FEES AND OCCUPATION TAX
LICENSE FEES AND OCCUPATION TAX
LICENSE FEES AND OCCUPATION TAX
LICENSE FEES AND OCCUPATION TAX
17
17
17
17
17
17
17 Distributor’s license fee (enter $250) .............................................................................................................
17
17
17 $
18
18
18 Enter operator’s number of devices ....................................................................
18
18
18
18
18
18
18
19
19
19
19
19 Operator’s license fee, 10 or more devices (enter $250) ..............................................................................
19
19
19
19
19 $
20
20
20
20
20 Operator’s license fee, less than 10 devices (enter 0) ..................................................................................
20
20
20
20
20
21
21
21
21
21 Total license fees (add lines 17 and 19 or 20) ...............................................................................................
21
21
21
21
21
22
22
22
22
22 Occupation tax (line 18 multiplied by $50 for the period of July 1, 1998 through Dec. 31, 1999; or $25 for
22
22
devices placed in operation after April 1, 1999 through Dec. 31, 1999) ........................................................
22
22
22
23
23
23 Total license fee, occupation tax, and penalty amount (total of lines 21, 22, and 25). Pay in full with return
23
23
23 $
23
23
23
23
Under penalties of law, I declare that I have examined this application and return, and to the best of my knowledge and belief,
it is correct and complete.
sign
here
Signature of Owner, Member, Partner, Corporate Officer,
Title
Date
Area Code and Telephone
or Person Authorized by Attached Power of Attorney
Number
FOR DEPARTMENT OF REVENUE USE ONLY
Serial Numbers of Decals Issued
Issued by
Date
PENALTIES
24
24
24
24
24
24
24 Number of mechanical amusement devices not properly registered .............................................................
24
24
24
25
25
25
25
25
25
25 Penalty (line 24 multiplied by $75) (include on line 23) .................................................................................
25
25 $
25
sign
here
Signature of Department of Revenue Representative
Title
Date
Mail this form 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 Copy
APPLICANT – Canary Copy
4-98
5-103-75 Rev.
Supersedes 5-103-75 Rev. 9-94
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