AMENDED
FORM
Nebraska Prepaid Wireless Surcharge Return
E911N
PLEASE DO NOT WRITE IN THIS SPACE
Tax Period
Nebraska ID Number
PRINT FORM
RESET FORM
Due Date:
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Check this box if your business has permanently closed, has been sold to someone else, or your license is no longer needed.
New owners must apply for their own prepaid wireless surcharge license.
1 Total gross sales from all prepaid wireless telecommunications services.
Combined filers should report total from all locations. ........................................................................
1
00
2 Total allowable deductions — see instructions ...................................................................................
2
00
3 Net taxable sales of prepaid wireless telecommunications services (line 1 minus line 2) ..................
3
00
4 Prepaid wireless surcharge (line 3 multiplied by 0.011) .....................................................................
4
5 Prepaid wireless surcharge collection fee (line 4 multiplied by .03) ...................................................
5
6 Net prepaid wireless surcharge due (line 4 minus line 5) ...................................................................
6
7 Previous balance with applicable interest at
% per year .............................................................
7
Reason for Amending:
8 Total balance due (line 6 plus line 7) ..................................................................................................
8
Under penalties of law, I declare that as a taxpayer or tax preparer, I have examined this return, including accompanying schedules,
and to the best of my knowledge and belief, it is correct and complete.
sign
here
Signature of Preparer Other Than Taxpayer
Date
Taxpayer Signature
Date
(
)
(
)
Daytime Phone Number
Daytime Phone Number
Email Address
Email Address
TH
THIS RETURN IS DUE ON OR BEFORE THE 20
DAY OF THE MONTH FOLLOWING THE TAX PERIOD INDICATED ABOVE.
Mail this return and payment to NEBRASKA DEPARTMENT OF REVENUE, PO BOX 98923, LINCOLN, NE 68509-8923.
, 800-742-7474 (NE and IA), 402-471-5729