Form 13Cce – Fill Out and Use This PDF

Nebraska ID Number (if applicable)

NAME AND LOCATION ADDRESS	NAME AND MAILING ADDRESS
Name	Name
Legal Name

CREDIT OR DEBIT CARD INFORMATION

1Name and address of bank issuing the credit or debit card.

2Provide only the last four digits and expiration date of the card. (A separate application is required for each credit or debit card.) Last four digits of the card: ____________________. Expiration date of the card: ____________________.

DOCUMENTATION REQUIRED

3Attach all of the following:

฀฀ ฀ •฀ Copy฀of฀the฀billing฀statement฀containing฀purchases฀made฀by฀this฀cardholder;

Note: Redact/blackout all but the last four digits of every credit or debit card number shown on each billing statement submitted with this application.

฀฀ ฀ •฀ Copy฀of฀the฀front฀side฀only฀of฀the฀credit฀or฀debit฀card;฀and

Note: Redact/blackout all but the last four digits of every credit or debit card number shown on each billing statement submitted with this application. Do not submit a copy of the back of the credit or debit card.

฀ ฀ ฀ •฀ Copy฀of฀a฀payment฀made฀to฀the฀issuing฀bank.฀ ฀

฀

฀

ADDITIONAL BILLING INFORMATION

4Will any person other than the sales tax exempt governmental entity or sales tax exempt organization be billed by the issuer of the card for any purchases made using the credit or debit cards identified on this application?

YES

NO

If Yes, please explain _________________________________________________________________________________________________.

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.

Title		Email Address

Instructions

Who May File This Application. Any sales tax exempt governmental entity or sales tax exempt organization, other

than the federal government and its agencies, that uses credit or debit cards which are directly billed to the exempt entity or organization to pay for its purchases of property, services, and lodging can ile this application.

Purpose of Application. Upon approval of this Application, the Nebraska Department of Revenue will issue an exemption permit that can be used in conjunction with a Nebraska Resale or Exempt Sale Certiicate, Form 13, and the credit or debit card identiied on this application to purchase property, services, and lodging exempt from sales, use, and lodging taxes. This exemption permit will conirm that any purchases made using the identiied credit or debit card will be directly billed and paid for by the sales tax exempt governmental entity or sales tax exempt organization.

Important: If more than one credit or debit card has been issued to the sales tax exempt governmental entity or sales tax exempt organization, a separate application is required for each card issued. The name on the card must match the name on this application. The exempt entity or organization is responsible for applying for a new exemption permit upon the expiration date of the current card.

Mail this application to: Nebraska Department of Revenue, PO Box 94818, Lincoln, NE 68509-4818.

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

7-287-2011 Rev. -2013 Supersedes 7-287-2011 Rev. 10-2012