Form 21a - Request For Abatement Of Interest - 1991

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Request for Abatement of Interest
Form
21A
Complete a separate application for each interest assessment.
Nebraska ID as It Appears on Your Return
Social Security Number (for individual income tax)
Please Do Not Write in This Space
Tax Period for Which Interest Was Assessed (For income tax,
Amount of Interest Assessed
PRINT
RESET
complete a separate request for each tax year.)
$
______________________
Name and Location Address
Name and Mailing Address
Name Doing Business As
Name
Legal Name
Street or Other Mailing Address
Zip Code
Street Address
City
State
City
State
Zip Code
A Request for Abatement of Interest Will Not be Considered Until the Tax Has Been Paid.
Check the Tax Program for Which Interest Was Assessed:
c
c
c
Sales or Use Tax
Motor Fuels Tax
Tobacco Products Tax
c
c
c
Income Tax Withholding
Litter Fee
Waste Reduction and Recycling Fee
c
c
c
Individual Income Tax
Lodging Tax
Other
c
c
Corporation Income Tax
Tire Fee
c
c
Fiduciary Income Tax
Wholesale Dealer Cigarette Tax
Interest abatements will be considered only for the following reasons. Please check the boxes that apply to you.
Interest was assessed due to an error or unreasonable delay by the Nebraska Department of Revenue (Department). (Provide a written explanation below.)
Interest was assessed due to erroneous written advice by the Department. This advice was given as a direct response to a request from the taxpayer
and the taxpayer reasonably relied upon the advice. (Attach a copy of the request and the written advice.)
Interest was attributable to an amount that was previously refunded without payment of interest. Interest can be abated up to the date the previous
refund was issued. (This reason does not apply to Motor Fuels taxes.)
Interest was assessed because of an amount erroneously refunded to the taxpayer, provided the taxpayer did not request the refund and it was not caused by
information supplied by the taxpayer. Interest may be abated for the first 90 days after the refund was issued.
Interest that was abated by the IRS on a related federal amount. (Attach a copy of the federal document showing abatement. This reason does not apply
to Motor Fuels taxes.)
Interest was assessed for taxes when the taxpayer complied with the tax laws by filing delinquent tax returns for prior periods after signing a Voluntary
Disclosure Agreement. (This reason does not apply to Motor Fuels taxes.)
Interest was assessed for taxes when the taxpayer was unable to file timely returns because of family illness or death. This could include the discovery
of unfiled returns for a deceased taxpayer.
Interest was assessed on taxes which were filed after the taxpayer’s records were destroyed due to a natural disaster. (Attach a written explanation.)
Explanation:
Under penalties of law, I declare that, as taxpayer or preparer, I have examined this application, and to the best of my knowledge and belief, it is
correct and complete.
sign
here
Signature of Owner, Partner, Member, Corporate Officer,
Title
Date
Daytime Phone
or Person Authorized by Attached Power of Attorney
Signature of Preparer Other Than Taxpayer
Title
Date
Daytime Phone
Email Address
For Nebraska Department of Revenue Use Only
Transaction Code
Amount
$
Interest Assessed
Comments:
$
Interest
Interest Abated
$
Line # ___
Remaining Interest
Line # ___
Authorized Signature
Date
You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Retain a copy for your records.
11-2013
7-201-1991 Rev.
Supersedes 7-201-1991 Rev. 6-2011

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