Nebraska Nebraska Nonresident Income Tax Agreement

Nebraska Nonresident Income Tax Agreement
Form 12N
PRINT FORM RESET FORM

Nebraska Nonresident Income Tax Agreement

FORM 12N

Please Do Not Write In This Space

Type of Organization (Check only one.)
Estate or Trust
Limited Liability Company

Partnership

S Corporation

Taxable Year of Organization

, 20	

Beginning

, 20

and Ending

Nonresident’s Taxable Year Including Organization’s Year End

, 20	

Beginning

, 20

and Ending

Nonresident Individual’s or
Nonresident Grantor’s Name and Mailing Address
Please Type or Print

	

Organization’s Name and Mailing Address

Name			

Name Doing Business As (dba)

				
	

Legal Name
Street or Other Mailing Address			
City 	

Street or Other Mailing Address
State	

	 Social Security Number	

ZIP Code	

Spouse’s Social Security Number	

City	
Nebraska ID Number	

State	

ZIP Code

Federal ID Number

I declare that I was a nonresident of Nebraska for the tax year shown above, and agree that I will: timely file a Nebraska Individual
Income Tax Return, Form 1040N; pay any income tax due; and that I will include in Nebraska adjusted gross income the portion of the
above-named organization’s Nebraska income attributable to my interest in that organization for the taxable year that includes the year
end date of the organization.

sign
here

This Agreement is binding upon my heirs, representatives, assignees, successors, executors, and administrators.

Signature of Nonresident Beneficiary, Member, Partner, or Shareholder

Date

Instructions

Who May File. An individual beneficiary, member, partner, or shareholder who was a nonresident of Nebraska during
any part of the organization’s taxable year may complete this Form 12N. A nonresident individual taxpayer includes a
nonresident grantor of a grantor  trust. An organization includes estates, trusts, S corporations, partnerships, or limited
liability companies (LLCs).
Do not file the Form 12N if the entity elected to be subject to Nebraska income tax for the taxable year. The election is only
available to partnerships and S corporations.
When and Where to File. A signed and dated Form 12N must be completed each year and delivered to the organization
prior to filing the organization’s Nebraska income tax return. The due date for the Nebraska income tax return for estates
and trusts, is the 15th day of the fourth month following the close of the taxable year. The due date for the Nebraska income
tax return of an S corporation, partnership, and LLC filing as an S corporation or partnership is the 15th day of the third
month following the close of the taxable year. The organization will file the Forms 12N with its Nebraska income tax return.
If Form 12N is Filed. The nonresident individual who has filed the Form 12N is required to timely file a Nebraska
Individual Income Tax Return, Form 1040N. This return must report the nonresident’s share of the organization’s Nebraska
income attributable to his or her interest in the organization during the taxable year, as well as any other income the
nonresident has earned from Nebraska sources.
A nonresident individual taxpayer who has a taxable year different from the taxable year shown on the Form 12N for the
estate, trust, S corporation, partnership, or LLC, must report the income on the Form 1040N that includes the tax year end
date of the organization.
If a Form 12N is Not Completed and Filed. If a Form 12N is not properly completed and attached to the organization’s
return for a nonresident individual, or completed and retained by the preparer when e-filing, the organization is required to
report and remit an amount equal to the highest individual income tax rate of the nonresident’s share of the organization’s
income derived from, or attributable to, Nebraska sources for the taxable year. The income tax withholding must be reported
on the Nebraska Schedule  K-1N, and the organization’s Nebraska return. When the nonresident individual files Form
1040N, the amount remitted by the organization will be allowed as a credit against the individual taxpayer’s Nebraska
income tax liability.
If the nonresident has no other Nebraska source income and the organization has filed a Nebraska Schedule K-1N and
remitted the appropriate amount for the nonresident, the nonresident is not required to file a Nebraska Form 1040N. The
income tax remittance will be retained by the Nebraska Department of Revenue in full satisfaction of the nonresident’s
income tax obligation to Nebraska. The nonresident may still file a return and claim a refund if one is due.
Publicly-traded partnerships are not subject to the income tax remittance provision stated above.
Attach this agreement to the organization’s Nebraska tax return, or retain it in the organization’s records if e-filing.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
8-065-2023