Form 21 - Request For Abatement Of Penalty Form - State Of Nebraska
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1Request for Abatement of Penalty
Form
21
Complete a separate application for each penalty assessment.
Please Do Not Write in This Space
Nebraska ID Number as It Appears on Your Return
Social Security Number (for individual income tax)
Tax Period for Which Penalty Was Assessed (For income tax,
Amount of Penalty Assessed
RESET FORM
PRINT FORM
complete a separate request for each tax year.)
$
______________________
Name and Location Address
Name and Mailing Address
Name Doing Business As
Name
Legal Name
Street or Other Mailing Address
City
Street Address
State
Zip Code
City
State
Zip Code
A request for abatement of penalty will not be considered until the tax and interest have been paid. For income tax programs,
do not include requests for abatement of underpayment of estimated tax penalties (Forms 2210N or 2220N).
Complete a
Form 21A
to request abatement of interest for specified situations only.
Check the Tax Program for Which Penalty Was Assessed. (Complete a separate Form 21 for each tax program.)
c
c
c
c
Fiduciary Income Tax
Bingo, Lottery, Raffle, or Lottery by Pickle Card
Tobacco Products Tax
Sales or Use Tax
c
c
c
c
Income Tax Withholding
Litter Fee
County and City Lottery (Keno)
Waste Reduction and Recycling Fee
c
c
c
c
Individual Income Tax
Lodging Tax
Mechanical Amusement Device Tax
Other
c
c
c
Corporate Income Tax
Tire Fee
Wholesale Dealer Cigarette Tax
Authorized Contact Person
Title
Daytime Phone
Email Address
I declare that my failure to comply with the provisions of the Nebraska tax laws and regulations was
not due to negligence or intentional disregard of the laws and regulations, but from the following causes
which I submit were beyond my reasonable control (attach a separate sheet if more space is needed):
Under penalties of law, I declare that, as taxpayer or preparer, I have examined this request, and to the best of my knowledge and belief,
it is correct and complete.
sign
here
Signature of Owner, Partner, Member, Corporate Officer,
Title
Date
Daytime Phone
or Person Authorized by Attached Power of Attorney
Signature of Preparer Other Than Taxpayer
Title
Date
Daytime Phone
Email Address
For Nebraska Department of Revenue Use Only
Tran Code
Amount
$
Penalty Assessed
Comments:
Penalty
$
Penalty Abated
Line # ___
$
Remaining Penalty
Line # ___
Authorized Signature
Date
You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
11-2013
7-103-1975 Rev.
Supersedes 7-103-1975 Rev. 12-2011
Retain a copy for your records.
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