"Application for Disabled Motor Vehicle Credit" - Nebraska

Application for Disabled Motor Vehicle Credit is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on July 1, 2013;
  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download "Application for Disabled Motor Vehicle Credit" - Nebraska

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State of Nebraska
Application for Disabled Motor Vehicle Credit
Motor Vehicle Owner Information
Vehicle Information
Full Name
Year
Make
Model
Address
VIN
Plate#
City State Zip
Registration Issuance Date
Phone Number
Registration Expiration Date
Email
Date Vehicle Removed From Service
, being duly sworn, deposes or affirms and says that he/she
(Name of Motor Vehicle Owner)
is the owner of the motor vehicle described above and is requesting a credit of the motor vehicle registration fees and
taxes because the vehicle has become disabled and is no longer in service.
Yes
No
Registration, plates and validation decals been surrendered to the County Treasurer?
r).
(If answer above is no, an affidavit explaining no surrender must be filed with the County Treasure
Signature of Motor Vehicle Owner
Subscribed and sworn to before me this
day of
,
Notary or County Seal
(Notary Public or Designated County Official)
Note: Notarization is required. Application must be filed within 60 days of the date the vehicle was disabled.
State Treasurer – Registration Fee Credit
County Treasurer – Motor Vehicle Fee/Motor Vehicle Tax
County:
Credit allowed:
Yes
No Amount:
Refer to number 2 below.
Credit allowed:
Yes
No Amount:
Refer to number 2 below.
Date:
(
Credit expires 1 year from this date.)
Date:
(
Credit expires 1 year from this date.)
Authorized signature
Authorized signature
Printed Name
Phone
Printed Name
Phone
1. Motor vehicle owner must submit properly completed Application for Disabled Motor Vehicle Credit to the County Treasurer
in the county where the vehicle is registered.
2. County Treasurer will notarize the Application for Disabled Motor Vehicle Credit, calculate the amount of motor vehicle fee
and motor vehicle tax to be credited and enter those amounts in the County Treasurer section above. County Treasurer will
calculate the amount of the registration fee to be credited and enter that amount in the State Treasurer section above.
3. The County Treasurer will then complete the County Treasurer – Motor Vehicle Fee/Motor Vehicle Tax portion of the
application and sign as authorization for the motor vehicle fee and motor vehicle tax credit.
4. The County Treasurer will then forward the application to the State Treasurer for authorization of the registration fee credit.
5. State Treasurer will sign the State Treasurer – Registration Fee Credit portion of the application to authorize the registration
fee credit and forward a copy of the application to the motor vehicle owner.
6. Motor vehicle owner must present a copy of the application within one year of the date of authorization to the County
Treasurer for credit to be applied towards the replacement vehicle.
Rev 7/2013
State of Nebraska
Application for Disabled Motor Vehicle Credit
Motor Vehicle Owner Information
Vehicle Information
Full Name
Year
Make
Model
Address
VIN
Plate#
City State Zip
Registration Issuance Date
Phone Number
Registration Expiration Date
Email
Date Vehicle Removed From Service
, being duly sworn, deposes or affirms and says that he/she
(Name of Motor Vehicle Owner)
is the owner of the motor vehicle described above and is requesting a credit of the motor vehicle registration fees and
taxes because the vehicle has become disabled and is no longer in service.
Yes
No
Registration, plates and validation decals been surrendered to the County Treasurer?
r).
(If answer above is no, an affidavit explaining no surrender must be filed with the County Treasure
Signature of Motor Vehicle Owner
Subscribed and sworn to before me this
day of
,
Notary or County Seal
(Notary Public or Designated County Official)
Note: Notarization is required. Application must be filed within 60 days of the date the vehicle was disabled.
State Treasurer – Registration Fee Credit
County Treasurer – Motor Vehicle Fee/Motor Vehicle Tax
County:
Credit allowed:
Yes
No Amount:
Refer to number 2 below.
Credit allowed:
Yes
No Amount:
Refer to number 2 below.
Date:
(
Credit expires 1 year from this date.)
Date:
(
Credit expires 1 year from this date.)
Authorized signature
Authorized signature
Printed Name
Phone
Printed Name
Phone
1. Motor vehicle owner must submit properly completed Application for Disabled Motor Vehicle Credit to the County Treasurer
in the county where the vehicle is registered.
2. County Treasurer will notarize the Application for Disabled Motor Vehicle Credit, calculate the amount of motor vehicle fee
and motor vehicle tax to be credited and enter those amounts in the County Treasurer section above. County Treasurer will
calculate the amount of the registration fee to be credited and enter that amount in the State Treasurer section above.
3. The County Treasurer will then complete the County Treasurer – Motor Vehicle Fee/Motor Vehicle Tax portion of the
application and sign as authorization for the motor vehicle fee and motor vehicle tax credit.
4. The County Treasurer will then forward the application to the State Treasurer for authorization of the registration fee credit.
5. State Treasurer will sign the State Treasurer – Registration Fee Credit portion of the application to authorize the registration
fee credit and forward a copy of the application to the motor vehicle owner.
6. Motor vehicle owner must present a copy of the application within one year of the date of authorization to the County
Treasurer for credit to be applied towards the replacement vehicle.
Rev 7/2013