Form 62 - Nebraska Uranium Severance Tax Return
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1
2Nebraska Uranium Severance Tax Return
FORM
62
PLEASE DO NOT WRITE IN THIS SPACE
Nebraska ID Number
Federal ID Number or Social Security Number
62-
RESET FORM
Period Covered by this Return
PRINT FORM
Beginning _________________________, 20 ____ and Ending ____________________, 20 ____
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Owners of Uranium Severed
Portion Owned by Each
Location Where the Uranium Was Severed
1 Gross quantity of uranium severed during this reporting period........................................................
1
2 Gross dollar value of uranium severed this reporting period .............................................................
2
3 Transportation and processing costs for uranium severed this reporting period ...............................
3
4 Value of uranium severed (line 2 minus line 3) ..................................................................................
4
5 Value of uranium severed from January 1 through the end of the last reporting period ....................
5
6 Total value of uranium severed through this reporting period (line 4 plus line 5) ..............................
6
5,000,000 00
7 Amount exempt from taxation ............................................................................................................
7
8 Total subject to uranium tax (line 6 minus line 7) ..............................................................................
8
9 Uranium tax due (line 8 multiplied by .02) .........................................................................................
9
10 Total uranium tax previously remitted since January 1 ..................................................................... 10
11 Balance due (line 9 minus line 10). Pay in full with return ................................................................. 11
Under penalty of law, I declare that I have examined this return and to the best of my knowledge and belief, it is correct and complete.
sign
here
Authorized Signature
Title
Date
Email Address
Phone Number
Mail original return and payment to: Nebraska Department of Revenue, PO Box 94818, Lincoln, NE 68509-4818
revenue.ne.gov, 800-742-7474 (NE and IA), 402-471-5729
11-2013
5-180-1991 Rev.
Retain a copy for your records.
Supersedes 5-180-1991 Rev. 10-2010
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