Beginning 20 and Ending 20
City State Zip Code City State Zip Code
Financial Institution Tax Credit (from Shareholder s
Name Name
Nebraska ID Number Federal ID Number Social Security Number Spouse s Social Security Number
Schedule Column I Form 1120NF) $
Street or Other Mailing Address Street or Other Mailing Address
Taxable Year of Financial Institution
8 632 2012
AMOUNT OF CREDIT Enter the individual shareholder s amount of calculated credit from Column I Shareholder s Schedule Form 1120NF Do not enter the total amount of the tax paid by the financial institution
FINANCIAL INSTITUTION S NAME AND MAILING ADDRESS
FORM NFC
FORM NFC MUST BE FILED WITH THE SHAREHOLDER S NEBRASKA INDIVIDUAL INCOME TAX RETURN FORM 1040N
INSTRUCTIONS
JOINT OWNERSHIP If shares are jointly owned separate Forms NFC must be issued to each joint owner reflecting each owner s proportionate share of the credit
PLEASE RETAIN A COPY FOR YOUR RECORDS
PROVIDE THIS STATEMENT TO THE SHAREHOLDER
SHAREHOLDER S NAME AND MAILING ADDRESS
Statement of Nebraska Financial Institution Tax Credit
WHO MUST FILE Every financial institution organized as an S corporation must complete a Statement of Nebraska Financial Institution Tax Credit Form NFC for each shareholder If the financial institution is owned by an S corporation bank holding company list the shareholders of the holding company This statement must be provided to the shareholder Do not file it with the Nebraska Financial Institution Tax Return Form 1120NF The individual shareholder must attach this statement to his or her Nebraska individual income tax return to claim the credit
