Form 13e - Nebraska Energy Source Exempt Sale Certificate - 1997
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Nebraska Energy Source Exempt Sale Certificate
13E
NAME AND MAILING ADDRESS OF PURCHASER
NAME AND MAILING ADDRESS OF SELLER
Name
Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Check Type of Certificate
Single Purchase
Blanket
If blanket is checked, this certificate is valid until revoked in writing by the purchaser.
Purchaser’s Account Number
Complete the requested information and check appropriate basis for exemption
Our purchase of ____________________________________________ , is exempt from Nebraska sales and use tax because:
A. We have been granted an exemption from payment of sales and use tax by the Nebraska Department of Revenue. Our
Certificate of Exemption number is 05 - ____________________ .
B. We are an exempt Nebraska governmental unit as set forth in Sales and Use Tax Regulation 1-093.04 and Revenue Rulings
1-99-3 and 1-00-1.
C. The energy source purchased is used directly by a Nebraska licensed for-profit hospital.
D. More than 50 percent of the energy source purchased is used directly in:
Processing or Manufacturing
Farming
Generation of Electricity
Irrigation
Refining
(See instructions on Determining Percent of Exempt Use)
If you checked Box D, you must provide a description of your business operations:
Any purchaser, or the agent thereof, who completed this exemption certificate for any purchase which is not exempt under the Nebraska Revenue
Act, as amended, shall in addition to any tax, interest, or penalty otherwise imposed, be subject to a penalty of $100.00 or ten (10) times the tax,
whichever amount is larger, on each billing exempted under this certificate. Under the penalties of law, I declare that I have examined this certificate
and to the best of my knowledge and belief, it is correct and complete.
sign
here
Authorized Signature of Purchaser
Title
Date Issued
NOTE: Sellers must keep this certificate as part of their records. Do not send it to the Nebraska Department of Revenue.
INSTRUCTIONS
for future purchases for up to three years; (3) Mark the
WHO MUST FILE. A Nebraska Energy Source Exempt Sale
appropriate exemption block indicating the category of
Certificate must be filed by every person claiming a sales and
exemption; (4) Have the certificate signed by an authorized
use tax exemption on the purchase of electricity, coal, gas, fuel
person; and (5) Indicate the date the certificate was issued.
oil, diesel fuel, tractor fuel, propane, gasoline, coke, nuclear
fuel, and butane.
PENALTIES. Any purchaser, or the agent thereof, who gives
WHERE TO FILE. The Form 13E must be given to the
a Nebraska Energy Source Exempt Sale Certificate, Form 13E,
seller at the time of purchase. It must be kept with the seller’s
to the seller for property which is purchased for a use other than
records for at least three years from the date of issuance.
those enumerated in the Nebraska Revenue Act, as amended,
may, in addition to other penalties, be subject to a penalty of
GOOD FAITH-PROPERLY COMPLETED CERTIFI-
$100 or ten times the tax, whichever amount is larger, for each
CATE. A purchaser must properly complete a certificate
instance of presentation and misuse. With regard to a blanket
before it can be accepted in good faith by the seller. An
certificate, the penalty shall apply to each purchase made during
incomplete or improperly completed certificate shall
the period the blanket certificate is in effect.
constitute evidence of a lack of good faith. To properly
complete the certificate, purchasers must:
Any purchaser, or the agent thereof, who fraudulently signs a
Form 13E with the intention to avoid payment of the tax may,
(1) Identify both purchaser and seller; (2) Mark the box for
in addition to the aforementioned penalty, be found guilty of
either the “single purchase” or “blanket” indicating whether
a Class IV misdemeanor.
the certificate is for a single purchase or is a blanket certificate
6-354-1994 Rev. 12-2001 Supersedes 6-354-1994 Rev. 10-1997
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