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FORM
Nebraska Withholding Certificate for Nonresident Individuals
W-4NA
•
Use Federal Forms 1099-MISC or 1042-S.
PAYOR’S NAME AND LOCATION ADDRESS
PAYEE’S NAME AND LOCATION ADDRESS
Name of Nebraska Payor
Payee’s First Name and Initial
Last Name
Address (Number and Street, or Rural Route and Box Number)
Address (Number and Street, or Rural Route and Box Number)
City, Town, or Post Office
State
Zip Code
City, Town, or Post Office
State
Zip Code
Nebraska ID Number
Social Security Number
21 —
• Lines 1 and 2, and 6 through 10 must be completed by the PAYOR.
1 Dates the services were performed in Nebraska ................................................................................... 1
2 Total payments for the personal services performed in Nebraska ........................................................ 2
• Lines 3 through 5 and line 11 may be completed by the PAYEE (attach additional schedule if necessary).
3 List the types and amounts of ordinary and necessary business expenses reasonably related
to Nebraska income (see instructions):
Type of Expense
Amount
3
Enter total line 3 amount here ........................................................................
4 List the names, addresses, Social Security numbers, and amounts paid to others for performances
or appearances and other fees reasonably related to Nebraska income (see instructions):
Name
Address
Social Security No.
Amount Paid
4
Enter total line 4 amount here ........................................................................
5 Total business expenses and payments for which you are claiming an
5
expense deduction (total of lines 3 and 4) ......................................................
6 50% limitation on expense deduction (line 2 amount multiplied by .50) .......
6
7 Enter the amount from line 5 or line 6, whichever is less ...................................................................... 7
8 Payments subject to Nebraska income tax withholding (line 2 minus line 7) ........................................ 8
9 If the amount on line 8 is less than $28,000, multiply the amount by .04 and enter
the result on line 9 — the amount to be withheld ................................................................................ 9
10If the amount on line 8 is $28,000 or greater, multiply the amount by .06 and enter
the result on line 10 — the amount to be withheld .............................................................................. 10
• Allocation to partners, shareholders, or members subject to Nebraska income tax (attach additional schedule if necessary).
11Enter in the space provided the partner’s, shareholder’s, or member’s name, Social Security number or federal ID number,
percent of allocation, and the amount of Nebraska income tax withholding allocated to each partner, shareholder, or member.
Social Security Number or
Percent of
Allocation Amount
Names of Partners, Shareholders, or Members
Federal ID Number
Allocation
TOTALS
100%
Under penalties of perjury, I declare that I have been authorized to make this statement and that the information disclosed in determining the amount of
individual income tax to be withheld and allocated from the payment received for personal services performed in Nebraska is, to the best of my knowledge and
belief, correct and complete.
sign
here
Signature of Payee or Authorized Agent
Signature of Preparer Other than Payee
Date
Date
Telephone Number
City
State
Zip Code
31
8-442-1988 Rev. 11-2012
Supersedes 8-442-1988 Rev. 1-2011