Form 501N Nebraska Monthly Withholding Deposit

1 You need to file a deposit but are currently not receiving this form; 2 You did not receive a Form 501N for the current period; 3 You lost/misplaced your Form 501N for the current period; or 4 Your business name location or mailing address listed on the Form 501N are not correct Nebraska ID Number Deposit for Month of Due Date Nebraska income tax withheld this period (Do not file this form if you are making payments electronically ) Please pay this amount $ Under penalties of perjury I declare that as taxpayer or preparer I have examined this deposit and to the best of my knowledge and belief it is correct and complete 8 008 1967 Rev 10 2012 Supersedes 8 008 1967 Rev 11 2011 Any person who is paid for preparing a taxpayer s Form 501N must also sign the deposit as preparer Authorized Signature Daytime Phone Signature of Preparer Other Than Taxpayer Daytime Phone Certain taxpayers are required to make payments electronically Electronic payments can be made using ACH Debit ACH Credit or by credit card See www revenue ne gov for additional information If you are required to make withholding payments electronically Form 501N will not be mailed Do not file Forms 501N which are photocopies which are from another period or which have not been preidentified Email Address Form 501N will not be mailed to taxpayers making electronic payments If required payment must be made by EFT Mail this form with your payment INSTRUCTIONS NAME AND LOCATION ADDRESS NAME AND MAILING ADDRESS NEBRASKA DEPARTMENT OF REVENUE PO BOX 98915 LINCOLN NE 68509 8915 NEBRASKA INCOME TAX WITHHELD THIS PERIOD Enter the amount of Nebraska income tax withheld during the calendar month for which this deposit is being filed If a deposit is not required until the second month all tax withheld for the first and second months must be remitted Nebraska Monthly Withholding Deposit Payments for the third month of a calendar quarter are made by filing the Nebraska Withholding Return Form 941N Form 941N and payment may be filed electronically or on a preidentified form Taxpayers required to make payments electronically should not send a check with Form 941N PENALTY AND INTEREST Penalty and interest may be imposed for failure to timely remit income tax withheld PLEASE DO NOT WRITE IN THIS SPACE PREIDENTIFIED RETURN This Form 501N is to be used only by the employer or payor whose name is printed on it Contact the Department if: SIGNATURES If filing a paper return Form 501N must be signed by the taxpayer partner member or corporate officer If the taxpayer authorizes another person to sign this deposit there must be a power of attorney on file with the Department SPECIFIC INSTRUCTIONS TAXPAYER ASSISTANCE See the Department s website at www revenue ne gov or call 800 742 7474 (NE and IA) or 402 471 5729 Title Date Address Date WHEN AND WHERE TO FILE The payment is due on or before the 15th day of the month following the calendar month covered by the deposit If not paying electronically mail to the Nebraska Department of Revenue PO Box 98915 Lincoln Nebraska 68509 8915 Checks written to the Department of Revenue may be presented for payment electronically WHO MUST FILE Monthly deposits are required when the amount withheld exceeds $500 for either the first or second month of a calendar quarter www revenue ne gov 800 742 7474 (NE and IA) or 402 471 5729 You must be licensed for Nebraska withholding with the Nebraska Department of Revenue (Department) prior to filing this deposit Complete Nebraska Tax Application Form 20 to apply for this license and mail it together with the Form 501N