FORM
Nebraska Credit Computation for Cigarettes and Tobacco
68
Products Sold to Native American Reservation Indians
Nebraska ID Number
Social Security or Federal ID Number
RESET FORM
Period Covered by Claim
Beginning
,
and Ending
,
PRINT FORM
The retailer below is located on this Indian Reservation in Nebraska
RETAILER’S NAME AND ADDRESS
WHOLESALER’S NAME AND ADDRESS
Name
Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
• A separate Form 68 must be completed to claim a credit for cigarette tax from any credit for Tobacco Products tax.
CIGARETTE TAX CREDIT COMPUTATION
1 Number of packs of 20 cigarettes or less sold to Native American
reservation Indians .....................................................................................
1
2 Credit claimed for exempt sales on packs of 20 cigarettes or less (line 1 multiplied by $.64) ........... 2
3 Number of packs of 25 cigarettes sold to Native American
reservation Indians .....................................................................................
3
4 Credit claimed for exempt sales on packs of 25 cigarettes (line 3 multiplied by $.80)....................... 4
5 Total amount of cigarette tax credit (line 2 plus line 4) ...................................................................... 5
TOBACCO PRODUCTS TAX CREDIT COMPUTATION
6 Credit claimed for tobacco products other than snuff (sold after 10-1-2009) sold to Native American
reservation Indians. Total unit cost of tobacco products sold $______________, multiplied by $.20
6
7 Credit claimed for snuff sold after 10-1-2009, to Native American reservation Indians.
Total ounces of snuff sold __________________, multiplied by $.44 ............................................... 7
8 Total amount of all Other Tobacco Products credits (line 6 plus line 7) ............................................. 8
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it
is correct and complete.
sign
here
Authorized Signature of Retailer
Date
Telephone Number
FOR WHOLESALER’S USE ONLY
• Attach Form 68 to your Cigarette Purchase Order Form if claiming a credit from line 5.
• Attach Form 68 to your Nebraska Tobacco Products Tax Return, Form 56, if claiming a credit from line 8.
Credit has been allowed for the amount shown on line 5 or 8 above on
(Invoice Number or Billing Description)
sign
here
Authorized Signature of Wholesaler
Date
Telephone Number
NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE — White Copy
WHOLESALER — Canary Copy
RETAILER — Pink Copy
, 800-742-7474 (NE and IA), 402-471-5729
12-2012
Supersedes 5-130-1976 Rev. 11-2009
5-130-1976 Rev.
1
2
Form 73a421 - Inventory Floor Tax For Cigarettes, Other Tobacco Products (otp), And Snuff - 2009
Financial
Form 04-522.2 - Inventory Report - Cigarette And Tobacco Products Tax - State Of Alaska - Department Of Revenue
Financial
