Form 21mf - Motor Fuels Application For Abatement Of Penalty
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1Form
Motor Fuels Application for Abatement of Penalty
21MF
Nebraska ID Number
Please Do Not Write in This Space
Federal Employer ID Number
PRINT FORM
RESET FORM
Name and Location Address
Name and Mailing Address
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Tax Program for Which Penalty Was Assessed:
c
c
c
Motor Vehicle/Diesel Fuels
Compressed Fuel
Motor Fuels Use
c
c
c
Petroleum Release Remedial Action Fee
Motor Fuels Carrier
Producer
c
c
c
Aircraft Fuels
Motor Fuels Terminal Operator
Other___________________________________
Amount of Penalty
Tax Period for Which Penalty Was Assessed
Note: Do not include interest. A request for abatement of penalty
will not be considered until the tax and interest have been paid.
$
I declare that my failure to comply with the provisions of the Nebraska Motor Fuels Tax Laws and Regulations was
not due to negligence or intentional disregard of the Laws and Regulations, but from the following causes which I submit
were beyond my reasonable control (attach a separate sheet if more space is needed):
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.
sign
here
Authorized Signature
Signature of Preparer Other Than Taxpayer
Title
Date
Address
Date
For Motor Fuels Division Use Only
Penalty Assessed
$ _______________
COMMENTS:
Penalty Abated
$ _______________
Remaining Penalty
$ _______________
Due and Payable
Authorized Signature
Date
Mail this application to: Motor Fuels Division, PO Box 98904, Lincoln, NE 68509-8904.
revenue.ne.gov/fuels, 800-554-3835, 402-471-5730
10-2013
3-439-1994 Rev.
Supersedes 3-439-1994 Rev. 11-2012
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