Form 36 - Tax Clearance Application

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Tax Clearance Application
FORM
36
Under
Neb. Rev. Stat. §§ 77-2707
& 77-27,110, if any person liable for sales and use taxes, withholding, or
income taxes sells a business or stock of goods, or quits the business, the buyer must withhold an amount from
the purchase price sufficient to cover any sales and use tax, income tax withholding, or income tax liability; or
obtain certification from the Nebraska Department of Revenue showing that all tax liabilities have been paid. If
the buyer fails to do so, he or she is liable for the taxes due to the extent of the purchase price, valued in money.
BUYER INFORMATION
Name
Business Name (if different)
Address (Street or other mailing address)
Business Address (Street or other mailing address)
City
State
Zip Code
City
State
Zip Code
Nebraska ID Number
Federal ID Number
NAME AND ADDRESS OF ALTERNATE RECIPIENT TO WHOM TAX CLEARANCE SHOULD BE SENT (if different from buyer)
Name
Business Name (if different)
Address (Street or other mailing address)
Business Address (Street or other mailing address)
City
State
Zip Code
City
State
Zip Code
I, the buyer, understand that under Nebraska law, any buyer purchasing a business or its assets has a statutory obligation to ensure any tax
liabilities are paid before the seller receives anything from the sale. I also understand that failure to do so results in the transfer of the liability to me, up to
the amount of the purchase price valued in money, including any assumption of debt. By signing this form, I acknowledge this responsibility and request
that the Nebraska Department of Revenue provide me with the amount of income tax withholding, sales and use tax, and income tax liability owed by
the seller, so that the proper amounts may be withheld from the purchase price. If there are no taxes currently owed, I request a Certificate of Clearance
stating this.
sign
here
Signature of Applicant/Buyer
Title
Date
SELLER’S INFORMATION
Name
Business Name (if different)
Address (Street or other mailing address)
Business Address (Street or other mailing address)
City
State
Zip Code
City
State
Zip Code
Nebraska ID Number
Federal ID Number
I, the seller, understand that under Nebraska law, all tax information is confidential. By signing this form, I grant the applicant/buyer a Power
of Attorney limited to obtaining this business’s confidential tax liability information, and authorize the Nebraska Department of Revenue to disclose
confidential income tax withholding, sales and use tax, and income tax liability information to the applicant/buyer.
sign
here
Signature of Seller
Title
Date
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818.
, 800-742-7474 (NE and IA), 402-471-5729
RETAIN A COPY FOR YOUR RECORDS.
7-290-2012

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