Form W-3N Nebraska Reconciliation of Income Tax Withheld

(or if annual filer tax reported for entire year) (line 6 Form 941N) 12 1 Federal Forms W 2 W 2G 1099 R and 1099 MISC If 50 or less and not e filing these forms attach the 1 Wage and Tax Statement Federal Form W 2; 10 Income TAX reported for the period ended June 30 (line 6 Form 941N) 10 11 Income TAX reported for the period ended Sept 30 (line 6 Form 941N) 11 12 Income TAX reported for the period ended Dec 31 13 Total Nebraska income tax reported (total of lines 8 through 12) 13 14 If line 13 is less than line 7 enter balance due 14 15 Penalty (see instructions) 15 16 Interest ( % per year of line 14 if filed or paid after January 31 see instructions) 16 17 BALANCE DUE (total of lines 14 through 16) 18 If line 7 is less than line 13 enter the amount of OVERPAYMENT The overpayment will be transferred to the 2 Nebraska wages tips and other compensation shown on Forms W 2 2 $ 2 Statement for Recipients of Certain Gambling Winnings Federal Form W 2G; 3 Distribution from Pensions Annuities Retirement or Profit Sharing Plans IRAs Insurance Contracts etc Federal Form 1099 R; and 3 Nebraska gambling winnings shown on Forms W 2G 3 4 Nebraska pensions annuities etc shown on Forms 1099 R 4 4 Statement for Recipients of Miscellaneous Income Federal Form 1099 MISC 5 Nebraska nonresident personal service payments and any payments to construction contractors subject to 6 Total payments subject to Nebraska withholding tax (TOTAL of lines 2 through 5) 6 7 Total Nebraska income tax withheld as shown on Forms W 2 W 2G 1099 R and 1099 MISC 7 8 Nebraska incentive withholding credits (see instructions) 8 9 Income TAX reported for the period ended March 31 (line 6 Form 941N) 9 Authorized Signature Date Signature of Preparer Other than Taxpayer Date Department's NebFile for Business program to e file these forms Enter number of forms 1 If annual filer skip to line 12 If the amount due is $2 or more pay in full with this form 17 Interest Due = (line 14) Rate of days mandatory 5% withholding (see instructions) shown on Forms 1099 MISC 5 Nebraska copy of these forms Taxpayers filing more than 50 forms with Nebraska withholding must use the next year Do not take any credit on Form 941N unless shown on line 12 of that form (complete section below) 18 $ See www revenue ne gov for information on e filing this return Tax Due x Interest x Number This form should be filed after completion of Form 941N Title Daytime Phone Address Telephone Number Under penalties of perjury I declare that as taxpayer or preparer I have examined this reconciliation and to the best of my knowledge and belief it is correct and complete 8 012 1967 Rev 11 2012 A penalty of $2 per statement not to exceed $2 000 may be imposed by the Department for failure to file the state copy of any Federal Withholding Forms) on or before the due date of Form W 3N or for failure to e file when filing more than 50 forms An overpayment of $2 or more will be refunded if this is your final return or if you indicate in your explanation that the overpayment exceeds the amount of tax you expect to owe next year An overpayment of $2 or more will be transferred to the next tax year The Department will verify the credit and enter it on your preidentified Form 941N Do not use the resulting credit until it appears on line 12 of your preidentified Form 941N Any extension granted does not extend the time allowed to submit copies of Federal Withholding Forms to employees or payees The employee s copy must be received by February 1 following the close of the calendar year If employment is terminated before the close of the year and the employee makes a request in writing then the employer must provide the employee s copy of the applicable form within 30 days after the last payment Any person paid for preparing a taxpayer s Form W 3N must also sign the form as preparer Check this box if e filing these forms Due Date E file or mail this W 3N and remit payment If you are filing more than 50 Forms W 2 or 1099 with Nebraska withholding you must file these forms electronically Email Address Employers reporting Nebraska withholding on more than 50 state copies of Forms W 2 and 1099 must e file these forms Please refer to www revenue ne gov for more information on e filing Form W 3N can now be filed using the Department s NebFile for Business filing program EXTENSION OF TIME An extension of time to file Form W 3N can be requested of the Department in writing The request should include the employer s or payor s Nebraska ID number and the period of time for which an extension is requested An extension may be granted for a period not to exceed 45 days from the original due date Mail this request to: Nebraska Department of Revenue PO Box 98915 Lincoln NE 60509 8915 Form W 3N is due on February 1 2013 along with payment of any amount shown on line 17 If required payment must be made by electronic funds transfer (EFT) Do not send any other remittance with the Form W 3N Checks written to the Nebraska Department of Revenue may be presented for payment electronically If you are licensed for withholding you must file a Form W 3N even if no payments were made which were subject to withholding or if the license was cancelled during the year If you are not licensed to report withholding or are changing name and/or address see instructions INSTRUCTIONS Interest is at the rate shown on line 16 Compute by calculating the number of days from February 1 to the date of payment Use the following formula to calculate the interest due: LINE 12 Enter only the amount of tax reported on line 6 of the Form 941N for the tax period ending December 31 Annual filers should enter the tax reported for the entire year Do not include any penalty and interest paid with your Form 941N LINE 17 Any balance due of $2 or more must be paid LINE 18 Any amount entered as an overpayment must be explained in the space provided As part of the explanation include the total Nebraska income tax withheld for each quarter and the total Nebraska income tax paid to the Department for each quarter LINE 5 Enter the amount of nonemployee compensation which was subject to withholding as nonresident personal service payments The amount entered should be the gross amount of payment before deduction of expenses Also include on this line any mandatory 5% income tax withholding made by construction contractors for payments made to subcontractors Go to www revenue ne gov then click on Construction Contractors for additional information LINE 8 Enter on line 8 the total amount of incentive credits used during this reporting year If the Department has preidentified an amount on this line you must correct it to reflect any amount of incentive credit taken on your fourth quarter Form 941N If the annual reconciliation of your withholding shows additional tax due and you wish to offset it with available incentive credits also add this amount to line 8 Attach the Incentive Withholding Worksheet which is available at www revenue ne gov LINES 2 THROUGH 5 Enter the total Nebraska income subject to withholding as shown on all Federal Withholding Forms When entering on lines 2 through 5 only include amounts once These lines must be completed regardless of the method used to file these forms (for example actual forms e filing or combined federal/state filing) LINES 9 THROUGH 11 The amounts for these lines have been completed with the amounts of tax reported on the quarterly returns received and processed by this Department Do not change any of these amounts without first contacting the Department These amounts are tax only and do not include any penalty or interest paid No payments of penalty and interest can be applied to the tax due NAME AND LOCATION ADDRESS NAME AND MAILING ADDRESS NEBRASKA DEPARTMENT OF REVENUE PO BOX 98915 LINCOLN NE 68509 8915 Nebraska ID Number Nebraska Reconciliation of Income Tax Withheld PENALTY AND INTEREST Penalty and interest are imposed for failure to timely remit income tax withheld A 5% penalty and interest are due with this form only if a balance due is shown on line 14 If line 14 is zero or a credit do not compute lines 15 and 16 PLEASE DO NOT WRITE IN THIS SPACE PLEASE RETAIN A COPY FOR YOUR RECORDS PREIDENTIFIED RETURN Form W 3N must be used only by the employer or payor whose name is printed on it If you have not received a preidentified Form W 3N for the reporting period request a duplicate from the Department Do not file Forms W 3N which are photocopies are from other tax periods or are not preidentified If the business name location or mailing address is not correct mark through the incorrect information and plainly print the correct information If you file your return electronically and need to report an address change please use the Nebraska Change Request Form 22 which can be found at www revenue ne gov Mail Form 22 to: Nebraska Department of Revenue PO Box 98903 Lincoln NE 68509 8903 REASON FOR OVERPAYMENT (Must complete if line 18 overpayment is claimed ) SIGNATURES Form W 3N must be signed by the taxpayer partner member or corporate officer If the taxpayer authorizes another person to sign the form there must be a power of attorney on file with the Department SPECIFIC INSTRUCTIONS Supersedes 8 012 1967 Rev 12 2011 Taxable Year THE NEBRASKA COPIES OF FORMS W 2 W 2G 1099 R AND 1099 MISC MUST BE E FILED OR ATTACHED TO THIS RECONCILIATION Visit www revenue ne gov or call 800 742 7474 (NE and IA) or 402 471 5729 WAGE/PAYMENT INFORMATION WHEN AND WHERE TO FILE E file or attach the Nebraska copies of the following federal withholding forms for each employee or payee who had Nebraska income tax withheld: WHO MUST FILE Every employer or payor withholding Nebraska income taxes from employees or payees must file a Nebraska Reconciliation of Income Tax Withheld Form W 3N You must apply for a withholding number on a Nebraska Tax Application Form 20 You will be issued a withholding certificate by the Nebraska Department of Revenue (Department) WITHHOLDING INFORMATION