1040 U.S.

Individual Income Tax Return 2025

Department of the Treasury—Internal Revenue Service
Form OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2025, or other tax year beginning , 2025, ending , 20 See separate instructions.
Filed pursuant to section 301.9100-2 Combat zone Deceased Spouse
Other
Your first name and middle initial Last name Your social security number
CAROL BERNEY 506 98 3140
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Check here if your main home, and your
spouse’s if filing a joint return, was in
1413 12th Ave the U.S. for more than half of 2025.
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code Presidential Election Campaign
Check here if you, or your spouse
Central City NE 688261505 if filing jointly, want $3 to go to
Foreign country name Foreign province/state/county Foreign postal code this fund. Checking a box below
will not change your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Check only Married filing jointly (even if only one had income) Qualifying surviving spouse (QSS)
one box. Married filing separately (MFS). Enter spouse’s SSN above If you checked the HOH or QSS box, enter the child’s name
if the qualifying person is a child but not your dependent:
and full name here:

If treating a nonresident alien or dual-status alien spouse as a U.S. resident for the entire tax year, check the box and enter their
name (see instructions and attach statement if required):
Digital Assets At any time during 2025, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes No
Dependents Dependent 1 Dependent 2 Dependent 3 Dependent 4
(see instructions) (1) First name
(2) Last name
If more
than four (3) SSN
dependents, (4) Relationship
see instructions
(5) Check if lived (a) Yes (a) Yes (a) Yes (a) Yes
and check with you more
here . . than half of 2025 (b) And in the U.S. (b) And in the U.S. (b) And in the U.S. (b) And in the U.S.
(6) Check if Full-time Permanently Full-time Permanently Full-time Permanently Full-time Permanently
student and totally student and totally student and totally student and totally
disabled disabled disabled disabled
(7) Credits Child tax Credit for Child tax Credit for Child tax Credit for Child tax Credit for
credit other credit other credit other credit other
dependents dependents dependents dependents
Check if your filing status is MFS or HOH and you lived apart from your spouse for the last 6 months of 2025, or you are legally
separated according to your state law under a written separation agreement or a decree of separate maintenance and you did not
live in the same household as your spouse at the end of 2025.
Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 46,957.
Attach Form(s) b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms
W-2G and d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld.
If you did not
f Employer-provided adoption benefits from Form 8839, line 31 . . . . . . . . . . . 1f
get a Form g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
W-2, see
instructions. h Other earned income (see instructions). Enter type and amount: 1h 0.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 46,957.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
c Check if your child’s dividends are included in 1 Line 3a 2 Line 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
c Check if (see instructions) . . . . . 1 Rollover 2 QCD 3
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
c Check if (see instructions) . . . . . 1 Rollover 2 PSO 3
6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
d If you are married filing separately and lived apart from your spouse the entire year (see inst.), check here
7a Capital gain or (loss). Attach Schedule D if required . . . . . . . . . . . . . . 7a
b Check if: Schedule D not required Includes child’s capital gain or (loss)
8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8 0.
9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7a, and 8. This is your total income . . . . . . . . . 9 46,957.
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
11a Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11a 46,957.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2025) Created 9/5/25
 Form 1040 (2025) Page 2

Tax and 11b Amount from line 11a (adjusted gross income) . . . . . . . . . . . . . . . . 11b 46,957.
Credits 12a Someone can claim You as a dependent Your spouse as a dependent
b Spouse itemizes on a separate return c You were a dual-status alien
d You: Were born before January 2, 1961 Are blind
Spouse: Was born before January 2, 1961 Is blind
Standard
deduction for— e Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . . 12e 15,750.
• Single or 13a Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13a
Married filing
separately, b Additional deductions from Schedule 1-A, line 38 . . . . . . . . . . . . . . . 13b
$15,750 14 Add lines 12e, 13a, and 13b . . . . . . . . . . . . . . . . . . . . . 14 15,750.
• Married filing
jointly or 15 Subtract line 14 from line 11b. If zero or less, enter -0-. This is your taxable income . . . . . 15 31,207.
Qualifying 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 16 3,509.
surviving
spouse, 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
$31,500
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 3,509.
• Head of
household, 19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
$23,625
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
• If you checked
a box on line 21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
12a, 12b, 12c, 22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 3,509.
or 12d, see inst.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 3,509.
Payments 25 Federal income tax withheld from:
and a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 4,002.
Refundable b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
Credits c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 4,002.
26 2025 estimated tax payments and amount applied from 2024 return . . . . . . . . . . 26
If you made estimated tax payments with your former spouse in 2025,
If you have a enter their SSN (see instructions):
qualifying child,
you may need to 27a Earned income credit (EIC) . . . . . . . . . . . . . . 27a
attach Sch. EIC. b Clergy filing Schedule SE (see instructions) . . . . . . . . . . . . . . . .
c If you do not want to claim the EIC, check here . . . . . . . . . . . . . . .
28 Additional child tax credit (ACTC) from Schedule 8812. If you do not want
to claim the ACTC, check here . . . . . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Refundable adoption credit from Form 8839, line 13 . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27a, 28, 29, 30, and 31. These are your total other payments and refundable credits . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 4,002.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 493.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 493.
Direct deposit? b Routing number 1 0 4 9 0 8 3 8 3 c Type: Checking Savings
See instructions.
d Account number 1 3 6 7 1 2 3
36 Amount of line 34 you want applied to your 2026 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to [Link]/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See instructions. Yes. Complete below. No
Designee Designee’s Phone Personal identification
name no. number (PIN)

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here
Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
Med Aide/CNA (see inst.)
Joint return? Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
See instructions. Identity Protection PIN, enter it here
Keep a copy for
(see inst.)
your records.
Phone no. (308)321-9419 Email address

Paid Preparer’s name Preparer’s signature Date PTIN Check if:

Preparer Self-employed
Use Only Firm’s name Self-Prepared Phone no.
Firm’s address Firm’s EIN
Go to [Link]/Form1040 for instructions and the latest information. BAA REV 01/02/26 [Link] Form 1040 (2025)
 Nebraska Individual Income Tax Return FORM 1040N
for the taxable year January 1, 2025 through December 31, 2025 or other taxable year:
, 2025 through , 2025
Your First Name and Middle Initial Last Name Please Do Not Write In This Space
CAROL BERNEY
Please Type or Print

If a Joint Return, Spouse’s First Name and Middle Initial Last Name

Current Mailing Address (Number and Street or PO Box)

1413 12th Ave
City
Central City
Your Social Security Number

5 0 6 9 8
DO NOT FILE
3 1 4 0
State
NE
Spouse’s Social Security Number
688261505
ZIP Code

6 1
High School District Code
6
During 2025, did you receive, sell, exchange, gift, or otherwise dispose of a digital asset or a financial interest in a digital asset?
1 0 0 4
Amended Return
Yes X No
Is the taxpayer claiming any benefits or tax credits from a business that is, or is owned in whole or part, by a foreign adversarial company?
(See instructions) Yes X No

(1) Farmer/Rancher (2) Active Military (1) Deceased Taxpayer(s)

(first name & date of death):

1 Federal Filing Status:

(1) X Single (3) Married, filing separately – Spouse’s SSN: (4) Head of Household
(2) Married, filing jointly and Full Name (5) Qualifying surviving spouse (QSS)
2a Check if YOU were: (1) 65 or older (2) Blind 2b Check here if someone (such as your parent) can claim you or
SPOUSE was: (3) 65 or older (4) Blind your spouse as a dependent: (1) You (2) Spouse
3 Type of Return:
(1) X Resident (2) Partial-year resident from / , 2025 to / , 2025 (attach Schedule III)
(3) Nonresident (attach Schedule III)
4 Nebraska personal exemptions. (Enter 1 in each line of 4a or 4b that applies):
1
a Yourself. If someone can claim you as a dependent, leave blank.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 a ______
b Spouse. Married filing jointly returns, if someone can claim your spouse as a dependent, leave blank . . . . . . 4 b ______
c Dependents, if more than three, see instructions Dependent's
First Name Last Name Social Security Number

5
FORM NOT FINAL
Federal adjusted gross income (AGI) (line 11, Federal Form 1040 or 1040-SR) Do not leave blank . . . . . . . . . 5
Total number of
dependents listed . . . . 4 c ______
Total Nebraska personal exemptions – add lines 4a, 4b, and 4c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
46,957.
C
1
00
6 Nebraska standard deduction (if you checked any boxes on line 2a or 2b above,
see instructions; otherwise, enter $8,600 if single; $17,200 if married, filing jointly or
qualifying surviving spouse; $8,600 if married, filing separately; or $12,600 if head of
household). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 8,600. 00
7 Total itemized deductions (line 17, Federal Schedule A – see instructions) . . . . . . . 7 00
8 State and local income taxes (line 5a, Schedule A, Federal Form 1040 or 1040-SR) 8 0. 00
9 Nebraska itemized deductions (line 7 minus line 8) . . . . . . . . . . . . . . . . . . . . . . . . . 9 0. 00
10 Nebraska standard deduction or the Nebraska itemized deductions, the larger of line 6 or line 9 . . . . . . . . . . . 10 8,600. 00
11 Nebraska income before adjustments (line 5 minus line 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 38,357. 00
12 Adjustments increasing federal AGI (line 13, from attached Nebraska Schedule I). . 12 00
13 Adjustments decreasing federal AGI (line 44, from attached Nebraska Schedule I) 13 0. 00
14 Nebraska Taxable Income (enter line 11 plus line 12 minus line 13). If less than -0-, enter -0-. Residents
complete lines 15 and 16. Partial-year residents and nonresidents complete NE Sch. III before continuing . . . 14 38,357. 00
15 Nebraska income tax (Partial-year residents and nonresidents enter the result
from line 9, NE Sch. III. Paper filers may use the Nebraska Tax Table.
All others must use Tax Calculation Schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1,518. 00
16 Nebraska other tax calculation:

DO NOT FILE
a Federal Tax on Lump-Sum Distributions (Federal Form 4972) 16 a $___________
b Federal tax on early distributions (lesser of Federal
Form 5329 or line 8, Sch. 2, Federal Form 1040 or 1040-SR) 16 b $___________
c Total (add lines 16a and 16b) . . . . . . . . . . . . . . . . . . . . . . . 16 c $___________
Residents multiply line 16c by 29.6% (x .296) and enter the result on line 16.
Partial-year residents and nonresidents enter the result from line 10, NE Sch. III 16 00
17 Total Nebraska tax before Nebraska personal exemption credit (add lines 15 and 16).
Do not pay the amount on this line. Pay the amount from line 59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1,518. 00
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Form 1040N (2025) Page 2
18 NE personal exemption credit for residents only ($171 times the number on line 4) . . 18 171. 00
19 Credit for tax paid to another state, line 6, Nebraska Schedule II
(attach Nebraska Schedule II and a copy of the other state's return) . . . . . . . 19 00
20 Credit for the elderly or disabled (attach copy of Federal Schedule R) . . . . . . . . . . 20 00
21 Community Development Assistance Act credit (attach Form CDN) . . . . . . . . . . . . 21 0. 00
22 Form 3800N nonrefundable credit (attach Form 3800N) . . . . . . . . . . . . . . . . . . . . . 22 00
23 Nebraska child/dependent care nonrefundable credit, only if line 5 is more
than $29,000 (attach a copy of Federal Form 2441 and see instructions) . . . . . 23 00

DO NOT FILE
24 Credit for financial institution tax (attach Form NFC) . . . . . . . . . . . . . . . . . . . . . . . . 24 00
25 Employer’s credit for expenses incurred for TANF (ADC) recipients (see instr.) . . . 25 00
26 Designated extremely blighted area tax credit (attach Form 1040N-EB) . . . . . . . . . . 26 00
27 NE employer tax credit for employing convicted felons.
Enter certificate number from Form ETC-A _________________________ . . . . . . . . 27 00
28 School Readiness Tax Credit for providers.
Enter certificate number from Form SR-3604 _____________________ 28 00
29 Child Care Tax Credit for Contributors.
Enter certificate number from Form CCTC-A __________________ . . . . . . . . . . . 29 00
30 Opportunity Scholarships Act credit for contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 00
31 Creating High Impact Economic Futures (CHIEF) credit. . . . . . . . . . . . . . . . . . . . . . . . . 31 00
32 Family Caregiver Tax Credit Act.
Enter certificate number from Form 3165 ____________________ . . . . . . . . . . . . . . 32 00
33 Nebraska Pregnancy Help Act Credit for contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . 33 00
34 Total nonrefundable credits (add lines 18 through 33) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 171. 00
35 Nebraska tax after nonrefundable credits. Subtract line 34 from line 17 (if line 34 is more than line 17, enter -0-)
If the result is greater than your federal tax liability, see instructions. If entering federal tax, check box . . . . 35 1,347. 00
36 Total Nebraska income tax withheld from Federal Forms W-2 (attach 2025 Forms,
see instructions). . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 36 1,754. 00
37 Total Nebraska income tax withheld from Federal Forms W-2G, 1099-R, 1099-MISC,
1099-NEC, etc. (attach 2025 Forms, see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . 37 0. 00
38 Total Nebraska income tax withheld from Nebraska Schedules K-1N
(attach 2025 Forms, see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 00

FORM NOT FINAL

39 Total Pass-Through Entity Tax (PTET) credit from Schedules K-1N
(attach 2025 Schedules K-1N, see instructions)
a Name:________________ b Nebraska ID Number:_______________
c Amount:______________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 00 C
40 2025 estimated income tax payments (include any 2024 overpayment credited to
2025 and any payments submitted with an extension request). . . . . . . . . . . . . . . . . . . 40 00
41 Form 3800N refundable credit (attach Form 3800N). . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 00
42 Nebraska child/dependent care refundable credit, if line 5 is $29,000 or less
(attach a copy of Form 2441N) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 00
43 Beginning Farmer credit from Form 1099 BFC (NDA NextGen). . . . . . . . . . . . . . . . 43 00
44 Nebraska earned income credit. Enter number of qualifying children 97 _________
Federal credit 98 $ _____________.00 x .10 (10%) (see instructions). . . . . . . . . . . . . 44 00
45 Credit for community college property taxes (attach Form PTC) . . . . . . . . . . . . . . 45 00
46 Credit for qualified Volunteer Emergency Responders (see instructions) . . . . . . . . . 46 00
47 Stillborn child tax credit (attach Birth Resulting in Stillbirth Certificate and
see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 00
48 Child Care Tax Credit for parent or legal guardian.
Enter certificate number from Form 7203_______________ . . . . . . . . . . . . . . . . . . . . 48 00
49 School Readiness Tax Credit for qualified staff member.
Enter certificate number from Form SR-3605____________________ . . . . . . . . . . . . 49 00
50 Reverse Osmosis System Tax Credit.
Enter certificate number from Form 1040N-OS___________________ . . . . . . . . . . . 50 00
51 Intellectual and Developmental Disabilities Direct Support Professional Tax Credit.

DO NOT FILE
Enter certificate number from Form 3157-A____________________ . . . . . . . . . . . . . . 51 00
52 Amount paid with original return, plus additional tax payments made after it was
filed (Amended Return Only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 00
53 Total payments and refundable credits (add lines 36 through 52). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 1,754. 00
54 Overpayment allowed on original return, plus additional overpayments of tax
allowed after it was filed (Amended Return Only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 00
55 Actual tax paid, line 53 minus line 54 (Original returns enter line 53). . . . . . . . . . . . . . 55 1,754. 00
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Form 1040N (2025) Page 3
56 Penalty for underpayment of estimated tax (see instructions). If you calculated a Form 2210N penalty of -0-
or greater, or used the annualized income method, attach Form 2210N, and check this box 96 . . . . . . . . . 56 00
57 Total tax and penalty for underpayment of estimated tax. Add lines 35 and 56 . . . . . . . . . . . . . . . . . . . . . 57 1,347. 00
58 Use tax due on taxable purchases where applicable sales tax was not collected. (see instructions)
Enter purchases subject to state tax 91 $ _______ State tax 92 $ _______ (purchases x 5.5%);
Enter purchases subject to local tax 93 $ _______ Local tax 94 $ _______ (purchases x local rate of ____ %)
95 Local code_______ (see local rate schedule);
Add state and local taxes and enter on line 58. If no use tax is due, enter -0- on line 58 . . . . . . . . . . . . . . . . . . 58 0. 00
59

DO NOT FILE
59 Total amount due. If line 55 is less than total of lines 57 and 58, subtract line 55 from total of lines 57 and 58 00
60 Overpayment. If line 55 is more than the total of lines 57 and 58, subtract the total of lines 57 and 58 from
line 55. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 407. 00
61 Amount of line 60 to be applied to your 2026 estimated tax (Original return only) 61 00
62 Wildlife Conservation Fund donation of $1 or more (Original return only). . . 62 00
63 Amount of line 60 you want refunded to you (line 60 minus lines 61 and 62) Your refund will generally be
issued by July 15, if your paper return is filed by April 15 (see instructions). Allow three months for an
amended return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 407. 00
Complete FOR AMENDED RETURNS ONLY
Are you filing this amended return because: Are you filing for a refund based on:
a. The Nebraska Department of Revenue (DOR) has YES NO a. The filing of a federal amended return or claim for refund? YES NO
notified you that your return will be audited? Attach copies of Federal Form 1045 or 1040X and supporting schedules.
b. The Internal Revenue Service (IRS) has corrected YES NO b. Carryback of a net operating loss or IRC § 1256 loss? YES NO
your federal return?
If Yes, year of loss: Amount: $
If Yes, identify office: Attach copies of Federal Form 1045 or 1040X with supporting schedules,
Attach a copy of changes from the Internal Revenue Service. and a completed Nebraska NOL Worksheet.

Reasons for Amending

Only Federal change (no NE change) Childcare Credit Change Dependent or personal exemption count change
(line 4)
Federal Filing Status change (singMe, MFJ, MFS, Other Credit Adjustment Earned Income Credit Change
HOH, QSS)

K-1N Change Property Tax Credit Change (include Other Reason for Amending (explain below)
previously claimed parcels on Form PTC).

FORM NOT FINAL

Use Form PTCX if this is the only change.
Explanation of Changes (Reference change and line number. If necessary attach additional sheets for explanation):

64a Routing Number 64b Type of Account 1 = Checking 2 = Savings

1 0 4 9 0 8 3 8 3 1

64c Account Number 1 3 6 7 1 2 3

64d Check this box if this refund will go to a bank account outside the United States.
Under penalties of perjury, I declare that, as taxpayer or preparer, I have examined this return and to the best of my knowledge and belief, it is true, correct, and complete.
sign
here
Keep a copy of
Your Signature Date
(308) 321-9419
Email Address
this return for
your records. Spouse’s Signature (if filing jointly, both must sign) Daytime Phone
paid Self Prepared
preparer’s Preparer’s Signature Date Preparer’s PTIN
use only
Print Firm’s Name (or your name if self-employed), Address and ZIP Code EIN Daytime Phone

A copy of the federal return and schedules must be attached to this return.

DO NOT FILE
E-file your return. NebFile offers FREE e-filing of your original state return for most Nebraska residents.
Mail returns requesting a refund to: Nebraska Department of Revenue, PO Box 98912, Lincoln, NE 68509-8912.
Mail returns not requesting a refund to: Nebraska Department of Revenue, PO Box 98934, Lincoln, NE 68509-8934.
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