Form L1l2 - Nebraska Advantage Rural Development Act Application
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1
2RESET FORM
Nebraska Advantage
L1L2
Rural Development Act Application
FOR NDR USE ONLY
Complete
Incomplete
1 A
Attach check for $500 application fee.
1A
1 B Employee Verification
1B
Is the taxpayer registered for E-Verify, the federal electronic verification program
a
used to confirm whether employees are authorized to work in the United States?
YES
NO
If YES, do you agree to use E-Verify for employees hired in Nebraska after the
b
date of application?
YES
NO
If the answer to question 1B(a) or 1B(b) is NO, do not complete the rest of the
c
application because you are not eligible to apply for this Nebraska tax incentive program.
d
Print out the “Company Information” from the E-Verify program and include it as an attachment.
2 Exact name of applicant and any other entities, including disregarded entities, to be part of the project
A
2A
Entity Name
Entity Type
FEIN
NE Income Tax ID No.
1
2
3
4
(If you need more room, attach a schedule)
If each entity in 2A is not included on the Affiliations Schedule, Form 851, attached as part of item 8,
B
provide an explanation of how the entities are related to each other.
2B
C What is the applicant’s tax year end? If it does not agree with the copy of the tax return
provided in item 8 below, provide an explanation.
2C
3 Describe the applicant’s business:
A Narrative:
3A
Federal Principal Business Activity Code:
B
3B
Federal Business Activity Title:
C Qualifying Business Activity (check the applicable boxes for the project):
3C
Assembly, fabrication, manufacturing, or processing of tangible personal property
Storage, warehousing, or distribution of tangible personal property
Transportation of tangible personal property
Conducting research, development, or testing for scientific, agricultural, animal husbandry,
food product, or industrial purposes
Livestock Production
Performance of data processing services
Performance of telecommunication services
Performance of insurance purposes
Performance of financial services (check applicable box below):
Financial institution subject to tax under Chapter 77, Article 38
Licensed by the Department of Banking and Finance
Licensed by the Securities and Exchange Commission
Administrative management of any activities, including the headquarter facilities relating to such
activities (provide a listing which lists the name and accounting code for each of the
qualifying departments)
Sale of tangible personal property (enter below the percentage of total sales in the base year
represented by the following categories of sales):
Sales at wholesale
Sales of tangible personal property assembled, or manufactured and processed
by the applicant
Sales of tangible personal property to a purchaser in one of the above listed activities
8-610-2005 Rev. 3-2012 Supersedes 8-610-2005 Rev. 9-2009
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