Form 1040n-V - Nebraska Individual Income Tax Payment Voucher - 2012

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FORM 1040N-V
Nebraska Individual Income Tax
Payment Voucher
2012
Your First Name and Initial
Last Name
PLEASE DO NOT WRITE IN THIS SPACE
If a Joint Return, Spouse’s First Name and Initial
Last Name
Current Mailing Address (Number and Street or PO Box)
City
State
Zip Code
Daytime Phone Number
Your Social Security Number
Spouse’s Social Security Number
Amount Remitted
00
Instead of mailing a check, use e-pay! Click “Make a Payment” on our website.
The total amount of tax due must be paid in full.
If payment is not made on or before April 15, 2013, the tax due is subject to penalty and interest.
, 800-742-7474 (NE and IA), 402-471-5729
Mail this voucher and payment to:
8-549-2012
NEBRASKA DEPARTMENT OF REVENUE, PO BOX 98903, LINCOLN, NE 68509-8903.

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