Application for Automatic Extension of Time
FORM
7004N
to File Nebraska Corporation, Fiduciary, or Partnership Return
Taxable year beginning
,
and ending
,
Name Doing Business As (dba)
RESET
PRINT
Legal Name
Street or Other Mailing Address
City
State
Zip Code
Federal ID Number
Nebraska ID Number
AUTOMATIC 5-MONTH EXTENSION
•
Check one of the boxes below if filing Federal Forms 1041 (except bankruptcy estates) or 1065.
Nebraska Fiduciary Income Tax Return, Form 1041N
Nebraska Return of Partnership Income, Form 1065N
AUTOMATIC 6-MONTH EXTENSION
•
Check one of the boxes below if filing Federal Forms 1041 (bankruptcy estate only), 1041-QFT, 1041-N, or 1065-B.
Nebraska Fiduciary Income Tax Return, Form 1041N
Nebraska Return of Partnership Income, Form 1065N
AUTOMATIC 7-MONTH EXTENSION
•
Check all appropriate boxes if filing Nebraska Form 1120N or 1120-SN.
Automatic seven-month filing extension from the
Extension in addition to the federal extension up to a
original due date.
maximum of seven months from the original due date.
Attach a copy of the Federal Form 7004, filed with the
Internal Revenue Service.
Is the corporation organized as an exempt organization?
YES
NO
Is the corporation a cooperative?
YES
NO
If Yes, enter the original due date of the cooperative's federal return _______________.
TENTATIVE TAX PAYMENT CALCULATION
• Entities filing a fiduciary or partnership return need not complete lines 1 through 10 below. A fiduciary or partnership must complete line 11.
1 Tentative income tax liability for taxable period before any applicable credits . . . . . . . . . . . . . . . . . . . 1
2 Premium tax credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Community Development Assistance Act credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Form 3800N nonrefundable credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Total nonrefundable credits (total of lines 2 through 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Subtract line 5 from line 1 (if the line 5 amount is more than the line 1 amount, enter -0-) . . . . . . . . . 6
7 Form 3800N refundable credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Estimated tax payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Other payments or credits, including any Beginning Farmer credit . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Total prior payments and credits (total of lines 7 through 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Tentative tax payment (line 6 minus line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Check this box if your payment is being made by electronic funds transfer (EFT).
If the corporation is a member of a unitary group of corporations filing a combined return, complete the following section.
ID NUMBERS
Name and Address of Each Member of the Unitary Group
Nebraska
Federal
Under penalties of perjury, I declare that I have been authorized to make this application, and that to the best of my knowledge and belief, the
statements made above are correct and complete.
sign
here
Authorized Signature
Date
Email Address
(
)
Title
Daytime Phone Number
Mail this application and remit payment (EFT, if required) to:
NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818
8-021-1968 Rev. 9-2012
, 800-742-7474 (NE and IA), 402-471-5729
Supersedes 8-021-1968 Rev. 12-2011