Nebraska E-file Opt-Out Record for Individuals                                       2021

     Paid tax preparers who filed more than 25 Nebraska individual income tax returns in 2021 must electronically 
     file (e-file) all of the Nebraska individual income tax returns they prepare in 2022. Taxpayers may request a 
     tax preparer to not e-file a return by signing this form. 
     Do not mail this form to the Nebraska Department of Revenue. The paid tax preparer should keep 
     the signed Nebraska E-file Opt-Out Record for Individuals for a period of at least three years after 
     the due date of the return. 

                                                             For Taxpayer’s Use Only
First Name and Initial                                       Last Name                       Your Social Security Number or ITIN

If Married, Filing Jointly, Spouse’s First Name and Initial  Last Name                       Spouse’s Social Security Number or ITIN
 
Current Mailing Address (Number and Street, or Rural Route and Box Number)                   Telephone Number

City                                                         State             Zip Code      Email Address

     I do not want my tax return filed electronically.

     Explanation: ______________________________________________________________________________________________________

      __________________________________________________________________________________________________________________

      __________________________________________________________________________________________________________________

Taxpayer
sign
here  Your Signature (If married, filing jointly, only one spouse must sign.)                                Date

                                                             For Paid Tax Preparer’s Use Only
Paid Tax Preparer’s Name                                                                     PTIN

Firm’s Name (If Applicable)                                                                  FEIN
 
Tax Preparer’s/Firm’s Address                                                                Telephone Number

City                                                         State             Zip Code      Email Address

Tax Preparer
sign
      Paid Tax Preparer’s Signature                                                                          Date
here

                              Do not mail this form to the Nebraska Department of Revenue.
                       The tax preparer should retain the signed form for a minimum of three years.

                              revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
                                                                                                                   8-664-2021