Form 4 - Nebraska Exemption Application For Sales And Use Tax Page 3
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3An organization providing day care, early childhood programs, and periodic care as defined in
is not exempt as a child-caring agency. NOTE: Foster care homes cannot
Neb. Rev. Stat. § 71-1910
qualify for this exemption.
5. A nonprofit Nebraska licensed child-placing agency. This type of agency is one which is authorized to place
children in foster family homes or to place children for permanent adoption.
6. Nonprofit organizations providing services exclusively to the blind (see
Sales and Use Tax Regulation
1-090).
7. A nonprofit Nebraska licensed home health agency, hospice or hospice service, or respite care service.
8. Nonprofit Nebraska licensed health clinics, when owned or controlled by two or more hospitals, or the
parent corporations of the hospitals, for the purpose of reducing the cost of health services; or which receive
federal funds through the United States Public Health Service for the purpose of serving populations that are
medically under-served.
Nonprofit Organization. The fact that an organization is nonprofit does not, by itself, entitle the organization
to an exemption from sales and use tax. The nonprofit organization must be one of the specific organizations
listed above to qualify for an exemption from sales and use tax. Suborganizations, though operating in
support of or under the guidance of an exempt organization, do not necessarily qualify for the exemption. A
sales and use tax exemption does not extend to a person or organization purchasing property which will be
given or donated to an exempt organization.
9. Interlocal Agreement Entity. A joint entity created by an Interlocal Agreement between two or more exempt
governmental agencies may apply for a sales and use tax exemption number. This joint entity is no longer the
exempt governmental unit and must separately apply to be exempt on its purchases. A copy of the Interlocal
Agreement must be submitted with the Form 4. The joint entity must be established as set out in the Interlocal
Cooperation Act.
SALES AND USE TAX EXEMPTION CERTIFICATE. Only the organization that is issued the exemption
certificate may make tax-exempt purchases of property or taxable services which will be used by and for the
exempt facilities or activities of the organization. The organization must give its supplier a
Nebraska Resale or
Exempt Sale Certificate, Form
13, when making tax-exempt purchases. When an organization repeatedly makes
the same types of purchases, it may give the retailer a blanket exemption certificate.
SPECIFIC INSTRUCTIONS
Answer all questions on the front of this application. Questions not relating to your organization should be
answered by writing “N/A” or “not applicable” on the appropriate line(s).
LINE 1. If you currently have or have previously been issued a Nebraska identification number such as a sales
tax, withholding, corporate, or partnership, enter that number. Do not enter your social security number.
LINE 2. Enter the federal employer identification number.
LINE 4. Provide a detailed description of the activities or services provided by your organization. If the activities or
services are set out in a brochure, pamphlet, or other similar document, please include it.
LINE 8. Enter the social security number, name, and address of the owners. A limited liability company must
identify each member. A partnership must identify each partner. A corporation must identify each corporate
officer. A sole proprietor must enter his or her social security number, name, and address. If additional space is
required, attach a list using the same format.
AUThORIZED SIGNATURE. This application must be signed by the owner, member, partner, corporate officer,
or other person authorized to sign by a
power of attorney
on file with the Nebraska Department of Revenue.
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