Form 7 - Claim For Overpayment Of Sales And Use Tax
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1Claim for Overpayment of
FORM
Sales and Use Tax
7
ne
• Attach supporting documents
dep
of
• Read instructions on reverse side
PLEASE DO NOT WRITE IN THIS SPACE
nebraska
department
of revenue
Nebraska Identification Number
Federal Employer I.D. or Social Security Number
NAME AND LOCATION ADDRESS OF CLAIMANT
NAME AND MAILING ADDRESS OF CLAIMANT
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Period Covered by this Claim
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
Beginning
,
and Ending
,
CLAIMED
APPROVED
1 Amount of Nebraska sales and use tax
ADD & CANCEL BMF
overpayment . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1
Amount of Local
_____________________
Overpayment
2 Local (city) sales or use tax overpayment:
2
City Name
Code
Amount
Amount of City Overpayment
BMF FIELD 29 ________
BMF FIELD 33 ________
BMF FIELD 36 ________
REF. TYPE ___________
Total
3 Total local sales or use tax overpayment
(total of line 2) . . . . . . . . . . . . . . . . . . . . . . . .
3
3
FORCE CODE ________
4 Total Nebraska and local sales or use tax
overpayment (total of lines 1 and 3) . . . . . . .
4
4
5 Select method of payment: (check one)
Issue refund warrant
Establish credit to sales or use tax account (Do not use credit until shown on return)
6 List the individual the Department of Revenue may contact for the purpose of obtaining additional information regarding this claim
(
)
Authorized Contact Person
Title
Telephone Number
BASIS FOR CLAIM — ATTACH APPROPRIATE DOCUMENTATION AND SEE INSTRUCTIONS
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. 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.
sign
(
)
(
)
here
Authorized Signature (Owner, Partner, Corporate Officer)
Telephone Number
Signature of Preparer Other Than Taxpayer
Telephone Number
Title (See Instructions)
Date
Address
Date
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
APPROVED
COMMENTS:
APPROVED AS ADJUSTED,
SEE COMMENTS OR LETTER
DATED____________________________
APPROVED AS AMENDED BY
YOUR ___________________ REQUEST
CREDIT ACCOUNT _________________
ISSUE REFUND WARRANT (Your
warrant will be issued in four to six
weeks.)
DISAPPROVED, SEE COMMENTS OR LETTER
Authorized Signature
Date
DATED ___________________________
Mail this claim and supporting documentation to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
NEBRASKA DEPARTMENT OF REVENUE – White and Canary Copies
TAXPAYER – Pink Copy
6-063-1967 Rev. 6-2001 Supersedes 6-063-1967 Rev. 4-1996
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