Fillable Wheel Tax Form - City Of Omaha Finance Department printable pdf download

CITY OF OMAHA WHEEL TAX EXEMPTION FORM

YEAR 20____

(Form to be completed only by owner/lessee of vehicle)

Exemption is only authorized if the vehicle is not driven in the City of Omaha more than 30 days during the annual vehicle registration

period. Separate forms are required for each vehicle for which exemption is claimed. A notarized wheel tax exemption form must accompany

each registration postcard. Please have this form notorized prior to coming in or when returning in person.

Vehicle Owner /Lessee________________________________________

Vehicle License # __________________________

Address_______________________________________________________

Zip Code___________________________________

Vehicle Description__________________________________________________________________________________________________________

(make)

(model)

(Vehicle ID # - VIN#)

1. Number of people who drive above vehicle one or more times per year ______________

2. Number of people included in (1) who are employed/attend school outside the home _________

3. List work addresses/schools of all persons who are included in (1) above. Be sure to include all jobs, including part time

positions. Also include any person who drives to any school in the Omaha area. Use the back of this form if you need

additional lines.

Street Address

Business/School

Zip Code

Days per week

(a)

(b)

(c)

(d)

4. Other vehicles owned or leased by any of the persons in (3)

(make)

(model)

Vehicle ID#

(a)

(b)

(c)

(d)

WORKSHEET FOR DETERMINING VEHICLE USAGE

List the total visits in each category (for all of the drivers of the vehicle).

Trips into the

Total Number

City Limits of Omaha

of visits per year

Trips to work/school/business/grocery

Total trips into Omaha for additional vehicles in #4.

Medical (hospital, doctor, dentist, veterinarian etc)

Other shopping (shopping malls, other shopping areas)

Vehicle 1 __________

Attending religious services

Entertainment (concert, movie theater, restaurants, etc)

Vehicle 2 __________

Library, gym, gas station

Visiting friends or relatives

Vehicle 3 __________

Other

Total trips into the City of Omaha per year for this vehicle

Vehicle 4 __________

SWORN STATEMENT

ACKNOWLEDGEMENT

I, _______________________________(print name)

State of Nebraska

owner/lessee of the above vehicle do hereby certify that this vehicle

s.s.

is not driven into the City of Omaha more than 30 days in total

during the registration period by any and all persons who may drive

the vehicle. I understand that pursuant to Section 16-23 of the

County of ___________________________)

Omaha Municipal Code, ownership or operation of a vehicle which

should be registered under Chapter 16, Article II is unlawful.

Each day such violation shall continue constitutes a separate

The foregoing instrument was subscribed and sworn

offense and is punishable by a fine up to $500 or by imprisonment of

before me this

of up to 6 months, or both.

____________ day of ______________, 20__

(month)

(signature of vehicle owner/lessee)

Notary Public

For questions regarding this form call the

City of Omaha Revenue Division at 444-6263 or 444-5469

↑

Affix Official Notary seal here

(August 2009)

Wheel Tax Form - City Of Omaha Finance Department

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