Nebraska Nebraska Exemption Application for Sales and Use Tax

Nebraska Exemption Application for Sales and Use Tax
Form 4
RESET FORM

Nebraska Exemption Application
for Sales and Use Tax

	 1	 Do you hold, or have you previously held, a
		 Nebraska ID Number?
			

Yes	

FORM

4

Please Do Not Write In This Space

2 Federal Employer ID Number

No
3	County of Business Location in Nebraska 

		 If Yes, provide the number:
Business Classification Code

Name and Location Address

Name and Mailing Address

	 Name Doing Business As (dba)

	Name

	 Legal Business Name
	 Street Address

	 Street or Other Mailing Address

	 City	

State	

Zip Code

	 City	

State	

Zip Code

	 4	 Provide a detailed description of your organization’s activities. If your organization performs multiple activities or, for health care organizations, operates facilities that offer multiple
		 levels of care, attach a list identifying each activity or care level (see Important Note on back). If you have a website, provide your website URL.

	 5	 Type of Ownership
	(1)	
c	Sole Proprietorship	

(7)	 c	Governmental	

(10)	 c	Cooperative

	(2)	
c	Partnership	(5)	
c	Foreign Corporation (Another State of Country)	

(8)	 c	Fiduciary (Estate or Trust)	

(11)	 c	Limited Liability Company

	(3)	
c	Nonprofit Corporation	 (6)	 c	S Corporation	

(9)	 c	Nonprofit Organization

	 6	 Accounting Basis	
	(1)	
c	Cash 	

(4)	 c	Corporation	

7	 Accounting Period
(1)	 c	Calendar Year — January 1 to December 31	

	(2)	
c	Accrual	(2)	
c	Fiscal Year — 12 Month Basis Ending
	(3)	
c	Other	(3)	
c	Fiscal Year — 52 or 53 Week Basis Ending
	 8	 Identify all Owners, Members, Partners, or Corporate Officers (One of the listed individuals must sign as the applicant.)
  Social Security Number	

Name, Address, City, State, Zip Code

	 9	 Check type of organization upon which you are basing your claim for sales and use tax exemption (see instructions):
		 Note: This application will be returned if the requested information is not attached.
	(1) 

c	A

nonprofit organization created exclusively for religious purposes (attach
copies of by-laws and either articles of incorporation or constitution).

(2)  c	 A nonprofit educational institution accredited and established under Sales Tax
Regulation 1-092, Educational Institutions. See instructions.
For 3, 4, 5, 7, and 8, attach a copy of your current license or certification. Attach a separate
page with a list of any additional types of health care or other activity provided.
	(3) 

c	 Health Care Facility. Only the following health care facilities can qualify to be
exempt. Check type of facility upon which you are basing your claim for sales and
use tax exemption (see instructions).

		

(a)	c	 Nonprofit Nebraska licensed hospital

		

(b)	c	 Nonprofit Nebraska licensed skilled nursing facility

		

(c)	c	 Nonprofit Nebraska licensed nursing facility

		

(d)	c	 Nonprofit Nebraska licensed assisted living facility

		

(e)	c	 Nonprofit Nebraska licensed intermediate care facility

		

(f)	 c	 Nonprofit Nebraska licensed intermediate care facility for persons with 	
		
developmental disabilities

		

(g)	c	 Nonprofit Nebraska licensed mental health center

		

(h)	c	Nonprofit Nebraska certified community-based developmental
		
disabilities service provider

sign
here

	
	

	

		

(i)	 c	 Nonprofit Nebraska licensed substance abuse treatment center

		

(j)	 c	 Nonprofit Nebraska center for independent living as defined in 	
		
29 U.S.C. § 796a

c	 A nonprofit Nebraska licensed child-caring agency (see instructions).
c	 A nonprofit Nebraska licensed child-placing agency.
	(6)  c	A nonprofit organization providing services exclusively to the blind (attach
	(4) 
	(5) 

by-laws and either articles of incorporation or constitution).

	(7) 

c	 A nonprofit Nebraska licensed home health agency, hospice care, or respite

	(8) 

c	A nonprofit Nebraska licensed health clinic when owned by one or more

	(9) 

c	 Organization established under the Nebraska Interlocal Cooperation Act with

care organization.

hospitals or the parent corporations of the hospitals (attach a copy of your
current license, by-laws, and either articles of incorporation or constitution);
or a nonprofit Nebraska licensed health clinic which receives federal funds
through the U.S. Public Health Service for the purpose of serving populations
that are medically underserved (attach a copy of your current license, Notice
of Grant Award and Letter issued by the U.S. Public Health Service, by-laws,
and either articles of incorporation or constitution).
all members consisting of exempt governmental units (attach a copy of the
Interlocal Agreement).	

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.

Signature of Owners, Member, Partner, Corporate Officer,	
Person Authorized by Attached Power of Attorney

Title	

Date	

Phone Number	

Email Address

For Nebraska Department of Revenue Use Only

c	Approved	
	 c	Disapproved

Comments:

	

	 Authorized Signature	

	

Exemption Code:

Date

Mail this application and attachments to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
6-068-1967 Rev. 6-2020 Supersedes 6-068-1967 Rev. 11-2017

Instructions
Who May File. Any qualified nonprofit organization wishing to make tax exempt purchases of property or taxable services,
to be used by and for the purposes of the exempt facility or activities, or portion of the facility, of the organization. Most
nonprofits do not qualify for sales and use tax exemption. The fact that an organization is nonprofit does not, by itself,
entitle an organization to be exempt from sales and use tax. Only the specific types of facilities or activities identified on this
form will qualify for an exemption. Suborganizations do not normally qualify for the exemption even though they operate
in support of or under the guidance of an exempt organization. An exemption does not extend to a person or organization
purchasing property which will be given or donated to an exempt organization. Please provide brochures, pamphlets,
website URL address, etc., providing details on what your organization does. Important Note: Any nonprofit organization
providing any of the types of health care or services in line 9, boxes 3, 4, 5, 7 or 8, on this form must first be licensed or
certified by the Nebraska Department of Health and Human Services (DHHS) to qualify for exemption from sales and use
taxes. There is no sales and use tax exemption available prior to these entities or facilities being licensed or certified. They
CANNOT issue either a Resale or Exempt Sale Certificate, Form 13, or a Purchasing Agent Appointment, Form 17, to
any retailer for purchases of property, or to any contractor relating to purchases of building materials for construction or
repair projects performed prior to being approved. After an entity becomes, licensed or certified, and upon completion of
the construction project, it may then submit a Form 4 to the Department. If approved, the entity may then file a Claim
for Refund of Sales and Use Tax, Form 7, for a refund of the sales tax paid or collected, or the use tax remitted, by any
contractor on building materials necessary to construct the facility. (See Sales and Use Tax Regulation 1-017.08B, Reg-1090.07C and Reg-1-092.05C).
Only the following organizations qualify for a sales and use tax exemption:
	

1.	 Nonprofit organizations created exclusively for religious purposes (see Reg-1-091, Religious Organizations).

	

2.	 Public or nonprofit private Nebraska educational institutions as identified in Reg-1-092, Educational Institutions.
Any nonprofit educational institution must be accredited regionally or nationally and have its primary campus in
Nebraska to qualify to be exempt from sales and use tax.

Important Note: Nonprofit organizations operating any of the following types of health care facilities or services in line 9,
boxes 3, 4, 5, 7 or 8, are only exempt on purchases for use at the facility, or portion of the facility, covered by the license that
is issued for the exempt type of health care provided. Any other types of health care provided are not exempt. Organizations
making purchases that are shared by an exempt and taxable portion of the organization must allocate the taxable purchase
and either remit use tax, or pay sales tax and claim a refund upon proof of proper allocation.
This exemption does not necessarily extend to all functions, activities, or purchases for an organization that provides
multiple levels of care. This exemption is not issued to the entire organization, but is issued only for the specific type of health
care. Organizations providing multiple levels of care, where a portion of the activities within the facility are exempt and
other activities are not exempt, must provide a list identifying exempt and non exempt portions of the facility or services
they provide. For these types of organizations, this exemption applies only to the purchases for that portion of the facility
that qualifies to be exempt. A separate Form 4 should be submitted for each facility if the organization operates more than
one health care facility that may qualify for exemption. Each application must include a copy of the state license issued for
that specific type of health care facility.
Example: Purchases are made by a nonprofit organization that operates a facility consisting of independent living,
licensed assisted living, and licensed skilled nursing care. This nonprofit organization must pay sales and use tax on
the purchases related to and used for the independent living portion of the facility. The sales tax exemption is only
on those purchases made for the assisted living and skilled nursing areas (for example, a specific wing or number
of beds within a designated area of a facility) (see Reg-1-090, Nonprofit Organizations).
	

3.	 The specific types of nonprofit licensed or certified health care facilities/providers that are identified in Box 3 of
line 9 may qualify for this exemption. The license or certification must be from the Nebraska DHHS.

	

4.	 A nonprofit Nebraska licensed child-caring agency. This type of agency is one which provides 24-hour daily care,
supervision, custody, or control of children in lieu of care or supervision normally exercised by parents in their own
home, and is licensed under Neb. Rev. Stat. §§ 71-1901 to 71-1904.

		An organization providing day care, early childhood programs, and periodic care as defined in Neb. Rev. Stat. § 71‑1910
is not exempt as a child-caring agency. Note: Foster care homes cannot qualify for this exemption.
	

5.	 A nonprofit Nebraska licensed child-placing agency. This type of agency is one which is authorized to place
children in foster family homes or to place children for permanent adoption.

	

6.	 Nonprofit organizations providing services exclusively to the blind.

	

7.	 A nonprofit Nebraska licensed home health agency, hospice or hospice service, or respite care service.

	

8.	 Nonprofit Nebraska licensed health clinics, when owned or controlled by one or more hospitals, or the
parent corporations of the hospitals, for the purpose of reducing the cost of health services; or which receive federal

funds through the U.S. Public Health Service for the purpose of serving populations that are medically underserved.
	

9.	 Interlocal Agreement Entity. A joint entity created by an Interlocal Agreement between two or more exempt
governmental units may apply for a sales and use tax exemption number. This joint entity is no longer the
exempt governmental unit and must separately apply to be tax-exempt on its purchases. A copy of the Interlocal
Agreement must be submitted with the Form 4. The joint entity must be established as set out in the Interlocal
Cooperation Act.

Sales and Use Tax Certificate of Exemption. Only the organization that is issued the numbered Exempt Organization
Certificate of Exemption may make tax exempt purchases of property or taxable services which will be used by and for the
exempt facilities or activities of the organization. The organization must give its supplier a Nebraska Resale or Exempt
Sale Certificate, Form 13, when making tax exempt purchases. When an organization repeatedly makes the same types of
purchases, it may give the retailer a blanket exemption certificate.
Employee Reimbursement. Purchases made by employees or members of an exempt entity or organization are subject
to sales or use tax. These purchases are taxable even if the employee or member is reimbursed for costs incurred while
conducting business for, or on behalf of, the exempt entity or organization.

Specific Instructions
Line 1. If you currently have, or have previously been issued, a Nebraska ID number (for example, a sales tax, income tax
withholding, corporate, or partnership), enter that number. Do not enter your Social Security number.
Line 2. Enter the federal employer ID number.
Line 4. Provide a detailed description of the activities or services provided by your organization. If the activities or services
are set out in a brochure, pamphlet, or other similar document, please include it.
Line 8. Enter the Social Security number, name, and address of all the owners, members, partners, or officers. A limited
liability company must identify each member. A partnership must identify each partner. A corporation must identify each
corporate officer. If additional space is required, attach a list using the same format.
Authorized Signature. This application must be signed by the owner, member, partner, corporate officer, or other person
authorized to sign by a power of attorney on file with the Nebraska Department of Revenue.