Form 43 - Nebraska Public Service Entity Tax Report Page 54
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57NEBRASKA SCHEDULE 97 - Merger or Acquisition
for Use by All Public Service Entities
FORM 43
If ownership has changed for any reason within the
Taxable Year
last year fill out the following questionnaire.
2013
Attach this schedule to Form 43
Name and Address as Shown on Form 43
County
Type of business: _________________________________________________________________________________
Did the type of business change because of the transaction? If yes, how? ______________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Date of transaction: _______________________________________________________________________________
List the parties to the transaction:
Buyer:
Seller:
What relationship to each other did the parties have prior to the transaction? ____________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Briefly describe any other consideration or conditions of the agreement (special financing, special
contracts, etc. ___________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Was the entire operating unit involved in the transaction? If no, what was excluded? _____________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What motivated the transaction?_____________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Briefly, how was the transaction allocated?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Authorized by Section 77-801
96-189-99 Revised 11/2012
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