Income Tax Job Application Form

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Important Message Nebraska Tax Application 1 Do you hold, or have you previously held a Nebraska ID number c Yes c No If Yes, provide the number: 2 Federal Employer ID Number (EIN) 3 County of Business Location Within Nebraska Name and Location Address of Business 20 Please Do Not Write In This Space RESET FORM PRINT FORM 4 For Department Use Only (print clearly) Name Doing Business As (dba) Form Name and Mailing Address Name Legal Name Business Street Address (Do Not Use PO Box) City State Is your Nebraska location within the city limits Street or Other Mailing Address Zip Code (1) c Yes City State Zip Code 5 Name and Address of Legal Entity/Owner (2) c No 6 Identify Owner and Spouse (if joint ownership), Partners, Members, or Corporate Officers (one of the listed individuals must sign as applicant).. Social Security Number Name, Address, City, State, Zip Code Title, If Corporate Officer 7 Type of Ownership (1) c Sole Proprietorship (2) c Partnership (3) c Nonprofit Corporation (4) c Corporation 8 Accounting Basis (1) c Cash (2) c Accrual (3) c Other (5) (6) (7) (8) c Foreign Corporation (another state or country) (9) c Nonprofit Organization c S Corporation (10) c Cooperative c Governmental (11) c Limited Liability Company c Fiduciary (Estate or Trust) 9 Accounting Period (Type of Year) (see instructions) (1) c Calendar – January 1 to December 31 (2) c Fiscal – 12 Month Ending (3) c Fiscal – 52 or 53 Week Ending 10 Location of Records (1) c Same as Location Address (2) c Same as Mailing Address (3) c Other Address (provide below) Address City State Zip Code 11 Reason for Filing Application – Check Appropriate Boxes..

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