Form 21 - Application For Abatement Of Penalty - 2008
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1Application for Abatement of Penalty
FORM
21
• Complete separate application for each assessed penalty
PLEASE DO NOT WRITE IN THIS SPACE
RESET FORM
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name Doing Business As (dba)
Name
Legal Name
Street or Other Mailing Address
City
Street Address
State
Zip Code
City
State
Zip Code
Tax Program for Which Penalty Was Assessed (Check One)
Sales or Use Tax
Fiduciary Income Tax
Oil and Gas Severance or Conservation Tax
Tobacco Products Tax
Withholding Tax
Litter Fee
Bingo, Lottery, Raffle, or Lottery by Pickle Card
Waste Reduction and Recycling Fee
Individual Income Tax
Lodging Tax
Mechanical Amusement Device Tax
Other
Corporate Income Tax
Cigarette Tax
Tire Fee
Social Security Number (Individual Income Tax)
Nebraska Identification Number as it appears on your return Tax Period for Which Penalty Was Assessed
Amount of Penalty
Note: Do not include interest or Forms 2210N or 2220N penalties. A request for abatement of penalty
$
will not be considered until the tax and interest have been paid. Complete Form 21A to request abate-
ment of interest for specified situations for income tax programs only.
Authorized Contact Person
Authorized Contact Person
Authorized Contact Person
Title
Title
Title
Daytime Phone
Daytime Phone
Daytime Phone
I declare that my failure to comply with the provisions of the Nebraska Tax Laws and Regulations was not due to
negligence or intentional disregard of the Laws and Regulations, but from the following causes which I submit were beyond
my reasonable control (attach a separate sheet if more space is needed):
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, Partner, Corporate Officer,
Signature of Owner, Partner, Corporate Officer,
Signature of Owner, Partner, Corporate Officer,
Signature of Owner, Partner, Corporate Officer,
Title
Title
Title
Title
Date
Date
Date
Date
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
or Person Authorized by Attached Power of Attorney
Signature of Preparer Other Than Taxpayer
Signature of Preparer Other Than Taxpayer
Signature of Preparer Other Than Taxpayer
Signature of Preparer Other Than Taxpayer
Title
Title
Title
Title
Date
Date
Date
Date
Daytime Phone
Daytime Phone
Daytime Phone
Daytime Phone
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
Tran Code
Amount
$
Penalty Assessed
COMMENTS:
Penalty
$
Penalty Abated
Line # ___
$
Remaining Penalty
Line # ___
Authorized Signature
Date
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
5-2008
7-103-1975 Rev.
Supersedes 7-103-1975 Rev. 3-2008
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