Form 93 - Nebraska Tire Fee Return

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FORM
Nebraska Tire Fee Return
93
Nebraska ID Number
Tax Period
Due Date
DO NOT WRITE IN THIS SPACE
RESET
PRINT
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Check this box if you no longer sell tires at retail in Nebraska.
1 Number of qualified tires sold .............................................................................................................
1
2 Number of qualified tires delivered outside Nebraska .................................. 2
3 Number of qualified tires sold to federal agencies ....................................... 3
4 Number of qualified tires sold for resale ....................................................... 4
5 Total tires not subject to the fee (total of lines 2, 3, and 4) .................................................................
5
$
6 Tire fee at $1 per tire (line 1 minus line 5) ..........................................................................................
6
00
7 Previous balance with applicable interest at
% per year and payments received through
7
Check this box if payment is being made electronically.
$
8 BALANCE DUE (line 6 plus line 7). Pay in full with return ..................................................................
8
Under penalties of law, I declare that I have examined this return, and to the best of my knowledge and belief, it is correct and complete.
sign
here
Signature of Owner, Partner, Member,
Date
Email Address
Corporate Officer, or Duly Authorized Individual
(
)
Title
Daytime Phone Number
(
)
Signature of Preparer Other Than Taxpayer
Date
Address
Daytime Phone Number
Instructions
Who Must File. Every person making retail sales in Nebraska of new tires for farm tractors, motor vehicles, trailers, or
semitrailers must obtain a Nebraska Tire Fee License and file a Nebraska Tire Fee Return, Form 93. To obtain a Nebraska Tire
20. After issuing your license, the Nebraska Department
Fee License, you must complete a
Nebraska Tax Application, Form
of Revenue (Department) will mail preidentified returns to you for each reporting period. Licensed retailers who no longer
sell tires at retail in Nebraska can cancel their license by placing a check mark in the box above line 1.
This return is due on or before the 25th day of the month following the reporting period indicated above.
Mail this return and payment to: Nebraska Department of Revenue, PO Box 94818, Lincoln, NE 68509-4818.
, 800-742-7474 (NE and IA), or 402-471-5729
1-100-1990 Rev. 4-2013 Supersedes 1-100-1990 Rev. 2-2012

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