21 Request for Abatement of Penalty

Nebraska ID Number as It Appears on Your Return

Tax Period for Which Penalty Was Assessed (For income tax,

complete a separate request for each tax year.)

Name Doing Business As (dba)

Legal Name

City

Email Address Phone Number

Zip Code

Name

Street or Other Mailing Address

City

Email Address Phone Number

State

Zip Code

7-103-1975 Rev. 8-2020

Supersedes 7-103-1975 Rev. 2-2018

Penalty Assessed

Amount Abated

Amount Denied

Unable to Process

FORM

Check the Tax Program for Which Penalty Was Assessed. (Complete a separate Form 21 for each tax program.)

You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.

revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729

Retain a copy for your records.

Name and Mailing Address

Name and Location Address

c Sales or Use Tax

c Income Tax Withholding

c Individual Income Tax

c Corporate Income Tax

c Bingo, Lottery, Raffle, or Lottery by Pickle Card

c County and City Lottery (Keno)

c Mechanical Amusement Device Tax

c Cigarette Tax

c Tobacco Products Tax

c Waste Reduction and Recycling Fee

c Other

c Fiduciary Income Tax

c Litter Fee

c Lodging Tax

c Tire Fee

For Nebraska Department of Revenue Use Only

Please Do Not Write in This Space

sign

here

Signature of Owner, Partner, Member, Corporate Officer, Title Date Daytime Phone

or Person Authorized by Attached Power of Attorney

Under penalties of law, I declare that, as taxpayer or preparer, I have examined this request, and to the best of my knowledge and belief,

it is correct and complete.

Signature of Preparer Other Than Taxpayer Title Date Daytime Phone

Basis of Request for Abatement: Explain how the failure to comply with Nebraska tax law was due to

causes that were beyond your reasonable control and not due to negligence or intentional disregard of

Nebraska law.

Authorized Contact Person Title Daytime Phone Email Address

Comments:

Date

Authorized Signature

Tran Code Amount

Penalty

Line # ___

Request for Abatement of Penalty

Social Security Number (for individual income tax)

Street Address

State

Email Address

Complete a separate application for each penalty assessment.

Amount of Penalty Assessed

$______________________

A request for abatement of penalty will not be processed until the tax and interest have been paid. For income tax programs, do

not include requests for abatement of underpayment of estimated tax penalties (Forms 2210N or 2220N) using this form.

Complete a Form 21A to request abatement of interest and any underpayment of estimated tax penalty.

RESET FORM

PRINT FORM

Who May File. Any taxpayer who has been assessed a penalty and has paid all tax and interest not subject to abatement,

may request an abatement of the penalty. A separate request must be completed for each penalty assessed. Do not use

this Form 21 to request abatement of individual or corporation underpayment of estimated tax penalties. Instead,

refer to the Individual Underpayment of Estimated Tax Penalty, Form 2210N, or Corporation Underpayment of

Estimated Tax Penalty, Form 2220N, for any exceptions and waivers of these penalties.

This form may not be used to request an abatement of interest. Use the Request for Abatement of Interest, Form 21A,

to request abatement of interest which is allowed only in certain specied situations, as explained on that form.

Where to File. This form must be mailed to the Nebraska Department of Revenue, PO Box 98903, Lincoln, NE

68509‑8903, or faxed to 402‑471‑5927.

Email. By entering an email address, the taxpayer acknowledges that DOR may contact the taxpayer by email. The

taxpayer accepts any risk to condentiality associated with this method of communication. DOR will send all condential

information by secure email or the State of Nebraska’s le share system. If you do not wish to be contacted by email,

write “Opt Out” on the line labeled “email address.”

Basis of Request for Abatement. Your Request for Abatement of Penalty must be supported by a complete

explanation of how the failure to comply with Nebraska tax law was due to causes that were beyond your reasonable

control and not due to negligence or intentional disregard of Nebraska law. If the space provided for the explanation

is not sufcient, a separate letter of explanation may be attached. Submitting this request does not guarantee abatement.

Reasons provided for abatement and prior abatement history will determine approval, partial approval, or denial of this

request.

Processing Procedure. The Nebraska Department of Revenue (DOR) will not process any Form 21 that does not

meet all of the following criteria: the Form 21 is lled out completely, including the basis for the failure to le and pay

timely due to causes that were beyond your reasonable control, and payment of all the associated tax and interest that is

not subject to abatement. DOR will review all documentation supporting the Form 21 prior to making a determination

of whether a request for abatement is approved, partially approved, denied, or cannot be processed.

Appeal Procedure. The denial of a request in its entirety, or in part, is considered a nal determination by DOR

and may be appealed. The requesting party must le an appeal with the District Court of Lancaster County within 30

days after the mailing of DOR’s nal determination in order to contest the determination.

Amount Denied. If the entire penalty is not abated, DOR will send a copy of this Form 21 with an explanation. If

the Request for Abatement of Penalty was denied in whole or in part and there is an amount shown on the Amount

Denied line, you must remit this amount or appeal DOR’s nal determination by following the above appeal procedures.

Unable to Process. If DOR was unable to process some or all of the Form 21, you may submit a corrected Form 21

to DOR or remit to DOR the amount of penalty on the Unable to Process line.

Payment. If you are a business and the penalty is related to a monthly or quarterly return, please pay the remaining

penalty with your next tax return. If you are mandated to make payments by electronic funds transfer (EFT), the

penalty and interest payment must also be made by EFT. If you are not mandated to make payments electronically

and do not le business tax returns on a monthly or quarterly basis, the remaining penalty should be remitted with

a copy of the Form 21.

Information. Questions may be directed to DOR at 800‑742‑7474 (NE and IA) or 402‑471‑5729.

Instructions