Form 5 Fillable Nebraska Exemption Application for Common or Contract Carrier's Sales and Use Tax - Includes Schedule A (7/2013)
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Attach Form 5 Schedule A to this application Mileage Information PLEASE DO NOT WRITE IN THIS SPACE See paragraph titled (1) c Calendar January 1 to December 31 (1) c Cash (1) c Same as Location Address (1) c Sole Proprietorship (10) c Cooperative (11) c Limited Liability Company (2) c Accrual (2) c Fiscal 12 Month Ending (2) c Partnership (2) c Same as Mailing Address (3) c Fiscal 52 or 53 Week Ending (3) c Nonprofit Corporation (3) c Other (3) c Other Address: (4) c Corporation (5) c Foreign Corporation (Another State or Country) (6) c S Corporation (7) c Governmental (8) c Fiduciary (Estate or Trust) (9) c Nonprofit Organization (A + B) (Department) for a common or contract carrier exemption or a sales tax motor fuels tax corporate or partnership ID (FAA) require your business to hold a Certificate of Public Convenience and Necessity or permit to (FMCSA) or Federal Aviation Administration (FAA) permit authority belonging to another person (See instructions) 1 Miles traveled transporting property owned by your company 2 Deadhead miles traveled to pick up or return to base when the property transported was owned by your company 3 Miles traveled under lease or trip lease to another carrier or company including all fronthaul and backhaul leased miles 4 Miles traveled transporting property pursuant to construction excavation or demolition contracts awarded to your company 5 Miles traveled transporting property pursuant to a contract for which your company is billing for materials property and 6 154 1971 Rev 7 2013 6 Miles traveled to go to a maintenance site or for testing purposes 7 Miles traveled under the Nebraska Public Service Commission (PSC) Federal Motor Carrier Safety Administration 8 Miles traveled pulling a trailer owned by another person when the property transported requires PSC or FMCSA permit 9 Miles traveled when the customer who owns the property transported provides the operators of the vehicles A computer printout or CD providing the same information as required on this form will be accepted instead of completing the a Nebraska ID Number? A statement regarding the type of property that is transported by the vehicles should also be included as part of the application Accounting Basis Accounting Period (Type of Year) and aircraft to be used in a common or contract carrier capacity Application is being made for a: Are any of the persons transported by the vehicles listed on Form 5 Schedule A employees of your company? Are any of the vehicles listed on Form 5 Schedule A used to transport rock sand or gravel? are just beginning operations answer these questions based on your anticipated business operations Are the operators of the vehicles listed on Form 5 Schedule A your employees? Are you paid by another company to deliver authority and the authority belongs to the person who owns the trailer Authorized Signature Authorized Signature This application must be signed by the owner partner member or corporate officer listed on billed or received payments from other persons for transporting their property plus all related deadhead miles Bus Class Code (Dept of Revenue Use Only) c APPROVED c Common Carrier Certificate of Exemption c Contract Carrier Certificate of Exemption c DISAPPROVED c YES c NO c YES c NO c YES c NO c YES c NO c YES c NO c YES c NO c YES c NO c Your Company c Company Where You Picked Up the Materials c Third Party capacity and will not qualify for this exemption Carrier s Sales and Use Tax Form 5; and Form 5 Schedule A cars pick up trucks vans and other business vehicles used for administration and safety purposes for hauling your own parts Column A All States Column A For each vehicle listed enter the total miles traveled in all states during the preceding 12 month period in which you Column B Column B For each vehicle listed enter the total actual miles traveled in all states for items 1 through 9 for the same period used Column C Column C Enter the total of the miles listed in Column A and Column B Column D Column D Enter the percentage of common or contract carrier usage (Column A divided by Column C) COMMENTS: Common or common or contract carrier All sales and use tax exemption certificates for common and contract carriers expire every Companies who file an International Registration Plan (IRP) application or renewal application may attach a copy of the application Construction excavation land leveling grading Contract Carrier County of Business Location in Nebraska Custom grain harvesting services? c YES c NO Daytime Phone Number Deadhead miles include: miles the vehicle traveled empty going to load the property; miles traveled empty between loads; and dealer s license? dealers; and water haulers will generally not qualify for this sales and use tax exemption These vehicles are used to transport their Describe Describe What is Transported Please list the specific types of property transported (for example grain cattle produce wood Do you buy and sell grain? Do you hold a grain Do you hold or have you previously held Do you lease or trip lease your vehicles to anyone? Do you provide any: Do you transport persons for hire? Do you transport property for hire? Does the Federal Motor Carrier Safety Administration (FMCSA) or Federal Aviation Administration Does the Nebraska Public Service Commission (PSC) require Does your company own any of the materials and property that are transported by the vehicles listed on Form 5 Schedule A? each partner A limited liability company Email Address Example 1 If you use a calendar year to report your income taxes use the period January 1 through December 31 Example 2 If you use a fiscal year to report your income taxes use the 12 month period of the fiscal year (for example EXEMPTION CODE Farm cooperative services? c YES c NO farm cooperatives; refuse (garbage) haulers; land leveling and excavation companies; custom grain harvesters; house movers; grain Federal Employer ID Number Federal Motor Carrier Safety Administration or Federal Aviation Administration to transport persons or property does fifth year regardless of when the certificate was issued FOR DEPARTMENT OF REVENUE USE ONLY FORM 5 General Information Only those motor vehicles trailers semitrailers watercraft or aircraft (vehicles) that are predominantly Have the vehicles listed on Form 5 Schedule A been used predominantly as a common or contract carrier since the date of purchase? Identify the owner partners members or corporation officers (one of the listed individuals must sign as the applicant) If No please explain how the vehicles have been used: If No please explain: If the application is approved the Department will issue a certificate of exemption to the company The company to whom If Yes attach a copy of the written agreement If Yes enter the FMCSA or FAA number and attach a copy of the permit If Yes enter the percentage of your total miles traveled under If Yes enter the PSC number and attach a copy of the permit If Yes give percentage of total miles driven that you transport rock sand or gravel: % If Yes please explain: If Yes provide the number: If Yes who bills the customer for the materials that you transport? (Check appropriate box ) If you are just beginning operations Instructions July 1 through June 30) Lease lease or trip lease to another carrier or company Attach a copy Legal Name Line 1 If you hold or have previously held a Nebraska ID number assigned by the Nebraska Department of Revenue Line 3 Enter the Nebraska county that you consider to be your principal business location in Nebraska Line 8 These records must contain Line 9 A sole proprietorship must identify the owner A partnership must identify line 9 An individual who is not listed on line 9 but signs the application must attach a completed power of attorney Lines 10 through 25 Answer these questions in a manner that clearly reflects your current and future operations If you List all motor vehicles Location of Records Mail this application to: Nebraska Department of Revenue PO Box 98903 Lincoln NE 68509 8903 Make and Model Mileage Information The mileage information is best explained by examples MILEAGE OR HOURS INFORMATION miles traveled empty when returning to home base after unloading the property hauled Deadhead miles between loads on a single must identify its members A corporation must identify each corporate officer If additional space is required attach a Name Address City State Zip Code NAME AND LOCATION ADDRESS NAME AND MAILING ADDRESS Name as Shown on Form 5 Name Doing Business As (dba) Nebraska Exemption Application for Common or Contract Carrier s Nebraska Exemption Application for Common or Contract Carrier s Sales and Use Nebraska Exemption Application for Common or Contract Carrier s Sales and Use Tax Form 5 Page 2 Nebraska Identification Number Nonqualified Use of Vehicles Vehicles used by construction contractors; rock sand and gravel companies; not automatically qualify the vehicles owned by the company for a sales and use tax exemption as a Nebraska licensed NOTE: number enter that number Do not enter your Social Security number of any written lease agreement or aircraft or contract or demolition services? c YES c NO or Person Authorized by Attached Power of Attorney own property and equipment and the miles traveled are not qualified common or contract carrier miles In addition passenger packages mail or any other property? Please make for your records Predominant Use Predominant use as a common or contract carrier means the vehicle is used more than 50% of the time to Provide a detailed description of your business operations: Refuse or garbage hauling services? c YES c NO requested information on that portion of this form Sales and Use Tax Schedule A schedule using the same format semitrailer semitrailers Signature of Owner Partner Member Corporate Officer Social Security Number Specific Instructions State State steel machinery mail) or indicate whether persons are being transported Street Address Street Address (Do not use PO Box ) Street or Other Mailing Address sufficient detail for the Department to audit and verify the sales and use tax exemption Supersedes 6 154 1971 Rev 7 2010 that is used predominantly as a common or contract carrier as defined in Sales and Use Tax Regulation 1 069 and desires the certificate is issued can use it to purchase vehicles that will be engaged predominantly as a common or contract carrier The fact that a company has been granted a certificate or permit issued by the Nebraska Public Service Commission tires and other property or for transporting personnel from job to job are not predominantly used in a common or contract carrier Title to complete Column A to purchase vehicles sales tax exempt must complete the: Nebraska Exemption Application for Common or Contract to transport person or property for hire and to purchase the repair parts for these vehicles sales tax exempt Total Miles trailer trailers transport the general public or the property of the general public for compensation To calculate predominant use divide the transport the persons or property listed on Form 5 Schedule A? transportation costs Transported trip are treated the same as the load Type of Ownership 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 Usage (A C) used for transporting persons or property for hire can qualify as a common or contract carrier It is necessary that the carrier comply vehicle s use to transport the general public or the property of the general public by the total use of the vehicle for all purposes Vehicles not included on the IRP application that are used in a common or contract carrier capacity must be listed on this form Water hauling services? c YES c NO watercraft What is Who Must File Any person who owns or leases a motor vehicle trailer or semitrailer watercraft or aircraft (vehicle) with all state agency regulations prior to filing for the sales and use tax exemption with the mileage information for each vehicle used in a common or contract carrier capacity instead of listing them on this form www revenue ne gov 800 742 7474 (NE and IA) 402 471 5729 you must estimate your mileage or hours You must give a complete description and mileage or hours information for each listed motor vehicle your business to hold a Certificate of Public Convenience to Zip Code Zip Code