Form 1120xnf - Amended Nebraska Financial Institution Tax Return - 2012
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1
2
3FORM 1120XNF
Amended Nebraska Financial Institution Tax Return
2012
Year beginning
,
and ending
,
Name of Financial Institution
PLEASE DO NOT WRITE IN THIS SPACE
RESET
PRINT
Street or Other Mailing Address
City
State
Zip Code
Nebraska ID Number
Federal ID Number
24 —
Type of financial institution – check applicable box:
(1)
Bank
(2)
Savings and Loan
(3)
Credit Union
(4)
Other
• Enter dollar amounts in ones, not in thousands (for example, fourteen million must be written as 14,000,000).
(B)
(A)
(C)
Computation of Tax
As Originally Reported
Net Change
Correct Amount
or As Adjusted
(Explain on Reverse Side)
1 Preceding year-end deposits ........................................
1
1
2 First quarter ending deposits ........................................
2
2
3 Second quarter ending deposits ...................................
3
3
4 Third quarter ending deposits .......................................
4
4
5 Fourth quarter ending deposits ....................................
5
5
6 Total deposits (total of lines 1 through 5) ......................
6
6
7 Average deposits (line 6 amount divided by 5) .............
7
7
8 Financial institution tax (line 7 multiplied by .00047) ....
8
8
9 Net income before income taxes and
extraordinary items (if net loss, enter -0-) .....................
9
9
10 Limitation amount (line 9 multiplied by .0381) .............. 10
10
11 Enter line 8 or line 10, whichever is less ....................... 11
11
12 CDAA credit (attach Form CDN) ................................... 12
12
13 Total Nebraska financial institution tax (line 11 minus
line 12. If less than zero, enter -0-) ............................... 13
13
14 Voluntary estimated tax payment (if any)...................... 14
14
15 Tax paid with original return, plus additional payments made after it was filed ........................................... 15
16 Line 14 plus line 15 ...................................................................................................................................... 16
17 Overpayment allowed on original return, plus additional overpayments allowed after it was filed .............. 17
18 Line 16 minus line 17 .................................................................................................................................. 18
19 Nebraska financial institution tax due (line 13 minus line 18) ...................................................................... 19
20 Penalty ......................................................................................................................................................... 20
21 Interest due .................................................................................................................................................. 21
22 BALANCE DUE (total of lines 19 through 21) ............................................................................................. 22
23 REFUND (line 18 minus line 13) Complete lines 24a, 24b, and 24c to receive your refund electronically
23
24a Routing Number
24b Type of Account
1 = Checking
2 = Savings
(Enter 9 digits, the first two digits must be 01 through 12, or 21 through 32.
Use the checking or savings account number from an actual check, not a deposit slip.)
24c Account Number
(Can be up to 17 characters. Omit hyphens, spaces, and special symbols.)
24d
Check this box if this refund will go to a bank account outside the United States.
Under penalties of perjury, I declare that I have examined this amended return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is correct and complete.
sign
here
Authorized Signature
Date
Email Address
(
)
Title
Daytime Phone
paid
preparer’s
Preparer’s Signature
Date
Preparer’s PTIN
use only
(
)
Firm’s Name (or yours if self-employed), Address, and Zip Code
EIN
Daytime Phone
Complete Nebraska Schedule I — Explanation of Changes, on reverse side.
Mail this amended return and remit payment (EFT, if required) to:
NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818.
, 800-742-7474 (NE and IA), 402-471-5729
8-700-2012
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