Form 7-I - Tax Incentive Claim For Refund Of Sales And Use Taxes
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Tax Incentive Claim for Refund
FORM
of Sales and Use Taxes
7-I
Nebraska ID Number
Federal Employer ID or Social Security Number
PLEASE DO NOT WRITE IN THIS SPACE
Claim Period
Beginning ________________________________ and Ending ________________________________
(Month/Day/Year)
(Month/Day/Year)
NAME AND LOCATION ADDRESS OF TAXPAYER
NAME AND MAILING ADDRESS OF TAXPAYER (If different from location)
Name
Name
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
AMOUNT CLAIMED
TYPE OF CLAIM
1 Nebraska sales and use
taxes paid . . . . . . . . . . . . . . .
1
LB 312
Direct Refund
2 Local sales and use taxes paid:
Credit Refund
LB 775
Local Taxing Jurisdiction
Amount of Tax
Aircraft Refund
LB 312 R & D
Project No.
LB 608
3 Total of line 2 . . . . . . . . . . . .
3
4 Total of lines 1 and 3. . . . . . .
4
5 Select payment method:
ACH payment;
Credit to sales/use tax account (do not use until credit appears on account); or
Direct Deposit
(Complete the routing and account information below to have your refund direct deposited).
Routing Number (must be 9 digits)
Check Type of Account:
(1) Checking
(2) Savings
Account Number (up to 17 digits)
Check this box if the refund will go to a bank outside the United States.
6 Person authorized to be contacted regarding this claim:
Authorized Contact Person (please print)
Email Address
Telephone Number
I declare under penalties of law that I have examined this claim, and to the best of my knowledge and belief, it is correct and complete.
I also declare that payment of this claim has not been previously made by the state, nor have I claimed or received a refund from the retailer.
sign
here
Authorized Signature (Owner, Partner, Member,
Telephone Number
Signature of Preparer Other Than Taxpayer
Telephone Number
Corporate Officer)
Print Name
Authorized Signature Name (please print)
Date
Title
Firm’s Name
Date
FOR DEPT. USE ONLY
ACTION TAKEN BY THE NEBRASKA DEPARTMENT OF REVENUE
AMOUNT APPROVED
ACH
YES
NO
APPROVED, ISSUE REFUND.
APPROVED AS REVISED,
DATE TO FINANCE/RO
1
SEE AMEND STATEMENT OR LETTER DATED ___________________.
______________________
Code
2
Local Tax Amount
Your refund, except for delayed refund amounts, will be issued in four to six weeks after approval.
REF. TYPE _____________
DENIED, SEE LETTER DATED __________________.
CAUTION: Any LB 312 local sales tax refund that exceeds $25,000 will be
BOX __________________
refunded in accordance with
Neb. Rev. Stat. §
77-5726(2)(e). Those marked
MOTOR VEHICLE TAX
with a “D” in the code section to the left are delayed refund amounts.
State _________________
Current refund amount to be issued: __________________________.
City __________________
3
Total delayed refund amounts:
__________________________.
Code _________________
Total refund amount:
__________________________.
Total
4
COMMENTS:
Department of Revenue Authorized Signature
Date
Mail this claim and supporting documentation to: NEBRASKA DEPARTMENT OF REVENUE, PO BOX 98903, LINCOLN, NE 68509-8903.
7-2012
6-392-2003 Rev.
Supersedes 6-392-2003 Rev. 4-2008
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