Form 7 - Claim For Refund Of Sales And Use Tax - 2016
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1Claim for Refund of Sales and Use Tax
Form
7
Attach supporting documents.
Nebraska ID Number
Federal Employer ID or Social Security Number
Please Do Not Write In This Space
PRINT FORM
RESET FORM
Claim Period
Beginning ______________________ , ________ and Ending ______________________ , ________
Name and Location Address of Claimant
Name and Mailing Address of Claimant
Name
Name
Legal Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Amount Claimed
Provide Basis For Claim and Attach Appropriate
1 Amount of Nebraska sales and
Documentation (See instructions.)
use tax paid . . . . . . . . . . . . .
1
2 Local sales and use tax paid:
Local Taxing Jurisdiction
Amount of Local Tax Overpayment
3 Total of line 2. . . . . . . . . . . . . .
3
4 Total of lines 1 and 3 . . . . . . . .
4
5 Select payment method:
Refund (complete information below) or
Credit to sales/use tax account (do not use until credit appears on
c
c
account). Complete the routing and account information below to have your refund direct deposited. The Department of Revenue strongly
encourages all refunds to be direct deposited.
Routing Number (must be 9 digits)
Check Type of Account:
c
(1) Checking
c
(2) Savings
Account Number (up to 17 digits)
c
Check this box if the refund will go to a bank outside the United States.
6 Person authorized to be contacted regarding this claim:
Authorized Contact Person (Please print.)
Title
Email Address
Phone Number
I declare under penalties of law that I have examined this claim, and to the best of my knowledge and belief, it is correct and complete.
sign
I also declare that payment of this claim has not been previously made by the state, nor have I claimed or received a refund from the retailer.
here
Authorized Signature (Owner, Partner, Member, Corporate
Phone Number
Signature of Preparer Other Than Taxpayer
Phone Number
Officer, or Person Authorized by Attached Power of Attorney)
Title (See instructions.)
Date
Address
Date
Action Taken by the Nebraska Department of Revenue
For Dept. Use Only
Direct Voucher
Tax Cat. __________
c
Approved
Comments:
Date to
c
Approved as Revised
Ref. Type _________
Finance
c
See Amended Statement
Force Code _______
_________________
c
See Comments
Approved
c
See Letter Dated
1
___________________
Code
2
Amount
c
Disapproved
c
See Comments
c
See Letter Dated
3
___________________
Total
4
Department’s Authorized Signature
Date
You may fax this form to 402-471-5927.
Mail this claim and supporting documentation to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Retain a copy for your records.
7-2016
6-063-1967 Rev.
Supersedes 6-063-1967 Rev. 2-2016
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