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N'Nebraska P z Nebraska Sales/Use Tax and Tire Fee Statement . FORM ' �� t REVENUE for Motor Vehicle and Trailer Sales PURCHASER'S NAME AND ADDRESS SELLER'S NAME AND ADDRESS \.-/ Name Name Mid Plains Center L111NV CIIALSIMI MOTORS l- et or Other Address Street or Other Address N 5 N. Elm 6110 ME M (V City State Zip Code City State Zip Code C GRAND ISLAND NE 68801 KEARNEY NE 68847 CD I PURCHASED VEHICLE/TRAILER DESCRIPTION cm Make Body Type Year Vehicle Identification Number(VIN) I Date of Purchase FORD 99 1FBSS31L3XHB81074 19/24/13 TRADE-IN VEHICLE/TRAILER DESCRIPTION Make Body Type Year Vehicle Identification Number(VIN) License Plate Number Was trade-in vehicle being leased? OYES 0 NO If Yes,enter 0 on line 2. <gTAX COMPU,TAriON—'See Instructions 1 Total sales price 1 $ 4, 900.100 2 Less trade-in allowance 2 N/iA 3 Less manufacturer's rebate assigned to dealer at time of sale 3 I 4 Tax base (line 1 minus lines 2 and 3) (if zero or less,enter 0) 4 $ t 5 Nebraska sales or use tax (line 4 multiplied by rate) 5 ice, 4 s>� 6 Local sales or use tax(line 4 multiplied by rate) 6 .? -r 'a-°`? ;at:74.:,,a .a 7 Total Nebraska and local tax due (line 5 plus line 6) 7 $ 8 Tire Fee (Number of new tires multiplied by$1) 8 1 9 Penalty for late payment 9 1 10 Interest for late.payment 10 1 11 BALANCE DUE (total of lines 7, 8, 9, and 10) 11 i$ I Any dealer or seller who willfully prepares a false or fraudulent Nebraska Sales/Use Tax and Tire Fee Statement may be found guilty of a Class IV felony and will,upon conviction,be fined not more than$10,000,or be imprisoned not more than five years or both.Under penalties of law, I declare that I.have sign mined this statemen and't is correct and complete. 9/24/13 here • Signature let /Signature of Purchaser or Agent of Purchaser Date 8$Mra i ai 4 pt le et cate,for MotorVehir a ktTTtattar males`- If exempt category 1 through 7 is claimed,requested information must be entered.Only categories 5 and 12 are exempt from the tire fee. Type of Exemption Type of Exemption R4 1 Purchase by an exempt organization holding a Certificate of Exemption issued ❑ 7 Purchase by a disabled person with funds contributed by the U.S.Department by the Nebraska Department of Revenue, of Veterans Affairs or the Nebraska Department of Health and Human Services Number 05- 1 47574( Finance and Support.Enter amount of contribution:$ .See instructions for"Purchase of a Motor Vehicle by a Disabled Person." ❑ 2 Vehicle will be used in a common or contract carrier capacity and the purchaser — - shown on the face of this form holds a current Certificate of Exemption issued by ❑ 8 Purchase by a governmental entity not engaged in the business of furnishing the Nebraska Department of Revenue.Number 05- gas,water,electricity,or heat. ❑ 3 Purchase by alessorofmotorvehicles.Salestax on the fair market lease payments ❑ 9 Vehicle is the subject of an intercompany sale between parent. subsidiary,or to be remitted under Nebraska Sales Tax Permit. brother-sister companies.Sales tax was paid by the seller company on its purchase Lessor's Sales Tax Number 01- of this vehicle.(Documentation required.) .be leased to a ❑10 Vehicle is a gift or received by inheritance and tax was previously paid by the ❑ 4 Purchase under the Lessor's Option and the motor vehicle will common or contract carrier who holds a valid Nebraska Certificate of Exemption donor,A gift is a voluntary transfer without any consideration.The donor paid the Number 05- tax on the previous transfer.If the person accepting the motor vehicle or trailer as a gift or inheritance assumes a lien,mortgage,or encumbrance,the amount Lessor must attach a copy of approved Nebraska Application for Election owing shall be subject to sales and use tax.(Documentation required.) of Lessors to Pay Sales and Use Tax on Cost of Motor Vehicles,Form 15. ❑11 Transfer of the vehicle during the creation, reorganization, or dissolution of ❑ 5 Purchase by a Native American Indian residing on a Nebraska reservation and a corporation, limited liability company, or partnership solely for voting stock the vehicle is registered at a location within the boundaries of the reservation. membership interest or partnership interest.Also,transfer of a vehicle as additional Tax Exemption ID Card Number: capital to an ongoing corporation,(Documentation required.) 6 Vehicle was purchased,licensed,and operated in a state other than Nebraska. ❑12 Purchase of a 30-day plate by a nonresident of Nebraska who does not intend Identify state: (Documentation required.) to remain in Nebraska more than 30 days from the date of purchase. Any purchaser or agent who completes this exemption certificate for any purchase which is not exempt under the Nebraska Revenue Act,as amended, will in addition to any tax, interest,or penalty otherwise imposed,be subject to a penalty of$100 or ten times the tax,whichever amount is larger Under penalt- =� • - - - 'xamined this certificate and to the best of my knowledge and belief,It is correct and complete. sign -elk 9/24/13 here --r r, p 01 Date FOR COUNTY USE ONLY • $ Tax Paid Date Paid NEBRASKA DEPARTMENT OF REVENUE—White and Green Copies COUNTY—Yellow Copy PURCHASER—Blue Copy SELLER—Pink Copy NEBRASKA DEPARTMENT OF REVENUE, PO BOX 94818, LINCOLN, NE 68509-4818 6-004-1967 Rev.7-2011 Supersedes 6.006-1967 Rev.7-2009