sign
here
Keep a copy of
this return for
your records.
Your Signature Date Email Address
Spouse’s Signature (if filing jointly, both must sign) Daytime Phone
Preparer’s Signature Date Preparer’s PTIN
Print Firm’s Name (or yours if self-employed), Address and Zip Code EIN Daytime Phone
Mail returns requesting a refund to: Nebraska Department of Revenue, PO Box 98912, Lincoln, NE 68509-8912.
Mail returns not requesting a refund to: Nebraska Department of Revenue, PO Box 98934, Lincoln, NE 68509-8934.
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Under penalties of perjury, I declare that, as taxpayer or preparer, I have examined this return and to the best of my knowledge and belief, it is true, correct, and complete.
18 Nebr. personal exemption credit for residents only ($142 times the number on line 4) 18
19 Credit for tax paid to another state, line 6, Nebraska Schedule II
(attach Nebraska Schedule II and a copy of the other state's return) ....... 19
20 Credit for the elderly or disabled (attach copy of Federal Schedule R) .......... 20
21 Community Development Assistance Act credit (attach Form CDN) ............ 21
22 Form 3800N nonrefundable credit (attach Form 3800N) ..................... 22
23 Nebraska child/dependent care nonrefundable credit, only if line 5 is more
than $29,000 (attach a copy of Federal Form 2441 and see instructions) ..... 23
24 Credit for financial institution tax (attach Form NFC) ........................ 24
25 Employer’s credit for expenses incurred for TANF (ADC) recipients (see instr.) ... 25
26 School Readiness Tax Credit for providers (see instructions) ................. 26
27 Designated extremely blighted area tax credit (attach Form 1040N-EB) ........ 27
28 Total nonrefundable credits (add lines 18 through 27).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
29 Nebraska tax after nonrefundable credits. Subtract line 28 from line 17 (if line 28 is more than line 17,
enter -0-). If the result is greater than your federal tax liability, see page 9 in the instructions. If entering
federal tax, check box and attach a copy of the federal return ................................. 29
30 Total Nebraska income tax withheld (attach 2021 Forms, see instructions)
a W-2 $ ________________ b K-1N $ ________________
c W-2G, 1099-R,1099-MISC, 1099-NEC or others $ ________________ ....... 30
31 2021 estimated income tax payments (include any 2020 overpayment credited to
2021 and any payments submitted with an extension request) ................ 31
32 Form 3800N refundable credit (attach Form 3800N) ........................ 32
33 Nebraska child/dependent care refundable credit, if line 5 is $29,000 or less
(attach a copy of Form 2441N)
.......................................... 33
34 Beginning Farmer credit from Form 1099 BFC (NDA NextGen)................ 34
35 Nebraska earned income credit. Enter number of qualifying children 97
Federal credit 98 $ .00 x .10 (10%) (attach pages 1-2 of federal return) 35
36 Nebraska Property Tax Incentive Act Credit (attach Form PTC) ............... 36
37 Credit for qualified Volunteer Emergency Responders (see instructions) ......... 37
38 School Readiness Tax Credit for qualified staff members (see instructions) ....... 38
39 Total refundable credits (add lines 30 through 38) ............................................... 39
40 Penalty for underpayment of estimated tax (see instructions). If you calculated a Form 2210N penalty of -0-
or greater, or used the annualized income method, attach Form 2210N, and check this box 96 ........ 40
41 Total tax and penalty. Add lines 29 and 40 ................................................... 41
42 Use tax due on taxable purchases where applicable sales tax was not collected. (see instructions)
Enter purchases subject to state tax 91 $__________ State tax 92 $___________ (purchases x 5.5%);
Enter purchases subject to local tax 93 $__________ Local tax 94 $_______ (purchases x local rate of ____%)
95 Local code__ __ __(see local rate schedule);
Add state and local taxes and enter on line 42. If no use tax is due, enter -0- on line 42. ................. 42
43 Total amount due. If line 39 is less than total of lines 41 and 42, subtract line 39 from the total of lines 41
and 42. Pay this amount in full. For electronic or credit card payment, check here and see instructions .... 43
44 Overpayment. If line 39 is more than total of lines 41 and 42, subtract total of lines 41 and 42 from line 39. .. 44
45 Amount of line 44 you want applied to your 2022 estimated tax ............... 45
46 Wildlife Conservation Fund donation of $1 or more ................... 46
47 Amount of line 44 you want refunded to you (line 44 minus lines 45 and 46) Your refund will generally be
issued by July 15, if your paper return is filed by April 15 (see instructions) ....................... 47
48a Routing Number 48b Type of Account 1 = Checking 2 = Savings
48c Account Number
48d Check this box if this refund will go to a bank account outside the United States.
