Form 4 - Nebraska Exemption Application For Sales And Use Tax
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3Nebraska Exemption Application
FORM
4
for Sales and Use Tax
1 Do you hold, or have you previously held, a
2 Federal Employer Identification Number
PLEASE DO NOT WRITE IN ThIS SPACE
Nebraska Identification Number?
YES
NO
RESET FORM
3 County of Business Location in Nebraska
If Yes, give number:
For Department Use Only
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name Doing Business As (dba)
Name
Legal Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
4 Provide a detailed description of your organization’s activities. If your organization performs multiple activities or, for health care organizations, operates facilities that offer multiple
levels of care, attach a list identifying each activity or care level (see Important Note on back).
5 Type of Ownership
(1)
Sole Proprietorship
(4)
Corporation
(7)
Governmental
(10)
Cooperative
(2)
Partnership
(5)
Foreign Corporation (Another State of Country)
(8)
Fiduciary (Estate or Trust)
(11)
Limited Liability Company
(3)
Nonprofit Corporation
(6)
S Corporation
(9)
Nonprofit Organization
6 Accounting Basis
7 Accounting Period
(1)
Cash
(1)
Calendar Year — January 1 to December 31
(2)
Accrual
(2)
Fiscal Year — 12 Month Basis Ending
(3)
Other
(3)
Fiscal Year — 52 or 53 Week Basis Ending
8 Identify Owners, Members, Partners, or Corporate Officers (One of the listed individuals must sign as the applicant.)
Social Security Number
Name, Address, City, State, Zip Code
9 Check type of organization upon which you are basing your claim for sales and use tax exemption (see instructions):
Note: This application will be returned if the requested information is not attached.
(4)
A nonprofit Nebraska licensed child-caring agency (see instructions).
(1)
A nonprofit organization created exclusively for religious purposes (attach
copies of by-laws and either articles of incorporation or constitution).
(5)
A nonprofit Nebraska licensed child-placing agency.
(2)
A nonprofit educational institution established under the provisions of Chapter 79
or 85 of the Nebraska Statutes.
(6)
A nonprofit organization providing services exclusively to the blind (attach by-
laws and either articles of incorporation or constitution).
For 3, 4, 5, 7, and 8, attach a copy of your current license or certification. Attach a separate
page with a list of any additional types of health care or other activity provided.
(7)
A nonprofit Nebraska licensed home health agency, hospice care, or respite
(3)
Health Care Facility. Check type of facility upon which you are basing your claim for
care organization.
sales and use tax exemption (see instructions).
(8)
A nonprofit Nebraska licensed health clinic when owned by two or more
(a)
Nonprofit Nebraska licensed hospital
hospitals or the parent corporations of the hospitals (attach a copy of your
(b)
Nonprofit Nebraska licensed skilled nursing facility
current license, by-laws, and either articles of incorporation or constitution); or a
nonprofit Nebraska licensed health clinic which receives federal funds through
(c)
Nonprofit Nebraska licensed nursing facility
the United States Public Health Service for the purpose of serving populations
(d)
Nonprofit Nebraska licensed assisted living facility
that are medically under-served (attach a copy of your current license, Notice of
Grant Award and Letter issued by the U.S. Public Health Service, by-laws, and
(e)
Nonprofit Nebraska licensed intermediate care facility
either articles of incorporation or constitution).
(f)
Nonprofit Nebraska licensed intermediate care facility for the
(9)
Organization established under the Nebraska Interlocal Cooperation Act with
mentally retarded
all members consisting of exempt governmental units (attach a copy of the
(g)
Nonprofit Nebraska certified community-based developmental
Interlocal Agreement).
disabilities service provider
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 Owners, Member, Partner, Corporate Officer,
Title
Date
Telephone Number
E-Mail Address
Person Authorized by Attached Power of Attorney
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
APPROVED
COMMENTS:
DISAPPROVED
Exemption Code:
Authorized Signature
Date
Mail this application and attachments to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 98903, LINCOLN, NE 68509-8903.
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
You may fax this form to (402) 471-5927.
8-2010
6-068-1967 Rev.
Supersedes 6-068-1967 Rev. 3-2009
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