Form 43 - Nebraska Public Service Entity Tax Report - 2013 Page 6
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63Nebraska Public Service Entity Report
FORM 43
* Must be postmarked by April 15, 2013
*Read instructions and complete enclosed schedules
Tax Year
*Attach copy of your federal annual report
2013
NAME AND LOCATION ADDRESS
Business Name
Nebraska I.D. Number
Street Address
Federal I.D. Number
City
State
Zip Code
NAME AND MAILING ADDRESS
Business Name
Street Address
City
State
Zip Code
Person to Contact Concerning this Report
Name
Title
Mailing Address
E-mail:
Telephone
Fax Number
Person to Whom the Property Tax Statement Should be Sent (if different from above)
Name
Title
Mailing Address
E-mail:
Telephone
Fax Number
Person to Whom the Public Service Entity Value Distribution Report should be Sent (if different from above)
Name
Title
Mailing Address
E-mail:
Telephone
Fax Number
Under penalties of law, I declare that as officer or preparer I have examined this report, including accompanying
schedules and notes, and to the best of my knowledge and belief, it is correct and complete. If filing electronicly, original copy
this form will be filed with the Nebraska Department of Revenue Property Assessment Division.
sign
here
Signature of Officer
Signature of Preparer Other than Officer
Title
Address
Date
Date
I authorize the exchange of information for this return, via e-mail to the e-mail address.
Signature and title of owner, officer, or authorized agent. _____________________________ Title ________________________
Mail completed reports and schedules to: Nebraska Department of Revenue, Property Assessment Division
301 Centennial Mall South, P.O. Box 98919, Lincoln, NE 68509-8919
Email completed reports and schedules to: pat.psu@nebraska.gov
1
96-160-99 Revised 11/2012
Authorized by Section 77-801
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