1 Name and address of bank issuing the card.
FORM
13CCE
Mail this application to: Nebraska Department of Revenue, PO Box 94818, Lincoln, NE 68509-4818.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
Phone Number
Signature of Owner, Partner, Member, Corporate Ocer, or Other Person
Authorized by Attached Power of Attorney
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.
Title
Date
sign
here
Email Address
Exemption Permit Application
Nebraska ID Number (if applicable)
7-287-2011 Rev. 5-2020 Supersedes 7-287-2011 Rev. 4-2018
Name and Location Address Name and Mailing Address
Name
Legal Name
Street Address
Name
Street or Other Mailing Address
City State Zip CodeCity State Zip Code
For Use of Credit or Debit Cards by Sales Tax Exempt Entities
Credit or Debit Card Information
2 Provide only the last four digits and expiration date of the card. (A separate application is required for each card.)
Last four digits of the card: ____________________. Expiration date of the card: ____________________.
Documentation Required
3 Submit all of the following documents:
• Copy of the billing statement page containing purchases made by this cardholder and the page containing the name of the exempt organization;
Note: Redact/blackout all but the last four digits of the card number shown on each billing statement submitted with this application.
• Readable copy of the card showing who the card was issued to, the last four digits of the card number, and the expiration date; and
Note: Redact/blackout all but the last four digits of the card number and the three-digit security code if that side is provided, before sending the copy.
• Copy of a payment made to the issuing bank.
Additional Billing Information
4 Will any person other than the sales tax exempt governmental entity or sales tax exempt organization be billed by the issuer of the card for any purchases made using the credit
or debit cards identied on this application?
YES NO If Yes, please explain _________________________________________________________________________________________________.
Instructions
Who May File This Application. Any sales tax exempt governmental entity or sales tax exempt organization that
uses credit or debit cards which are directly billed to the exempt entity or organization to pay for its purchases
of property, services, and lodging can le this application. The federal government and its agencies and the state of
Nebraska and its agencies cannot use this Application since they have specic cards that they use to document their
exempt status.
Purpose of Application. Upon approval of this Application, the Nebraska Department of Revenue will issue an
exemption permit that is to be used in conjunction with a Nebraska Resale or Exempt Sale Certicate, Form 13, and
the credit or debit card identied on this application to purchase property, services, and lodging exempt from sales,
use, and lodging taxes. This exemption permit will conrm that any purchases made using the identied credit or debit
card will be directly billed and paid for by the sales tax exempt governmental entity or sales tax exempt organization.
Important: If more than one credit or debit card has been issued to the sales tax exempt governmental entity or sales
tax exempt organization, a separate application is required for each card issued. The name on the card must match the
name on this application. The exempt entity or organization is responsible for applying for a new exemption permit
upon the expiration date of the current card.
