EMPLOYERS SHOULD ONLY USE THIS FORM FOR TAX HEARINGS. This form allows employers on Tax hearings to notify the Tribunal of an employer's contact telephone number, witnesses (if any) and their telephone numbers along with the certificate of service. Employers may use this form if the employer did not receive a Telephone Information Return Form with the Notice of Telephone Hearing form or lost the original Telephone Information Return Form sent in the mail. 

This form may be completed online, and answers may be inserted in the areas provided. The form cannot be saved with the information entered. To save the information, the form must be printed. Please remember to SIGN and DATE the form prior to returning it to the Tribunal. Users may also print the form and fill in the answers by either printing or typing the answers neatly in the space provided.

CASE NUMBER: Please list the case number in the upper right hand side of this form.

EMPLOYER'S NAME: Please provide the employer's name as listed with the Nebraska Department of Labor. If the employer also knows its experience account number, please list the number on the form. The account number is not necessary if the case number is listed on the form. 

HEARING DATE AND TIME: Please list the date and time of the hearing in the appropriate spaces. 

NAME AND TITLE OF EMPLOYER"S WITNESSES: Please list the full name and title of each witness, along with the telephone number (including area code or extension) where they can be reached at the time of hearing. 

NAME AND ADDRESS OF EMPLOYER'S ATTORNEY OR REPRESENTATIVE: In the space provided, list the name, address and contact telephone number of the employer's attorney or hearing representative. If the employer does not have an attorney, it should leave this area blank.

CERTIFICATE OF SERVICE: The employer does not need to complete the Certificate of Service if it did not submit documents to the Tribunal. If the employer submitted documents, it will also need to send copies to the Nebraska Department of Labor or any other party. By completing the Certificate of Service, the Tribunal knows that the employer sent other interested parties its documents before the hearing. If the employer did not submit any documents to the Tribunal, this space may be left blank.

SIGNATURE LINE: Please remember to SIGN and DATE this subpoena before sending it to the Nebraska Appeal Tribunal.

NAME / TITLE / ADDRESS, ETC: Please complete the information regarding the individual that completed the Certificate of Service.

Please return the TAX HEARING TELEPHONE INFORMATION RETURN FORM to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. The employer may also fax this to the Tribunal at (402) 471-1734.

The Tribunal has specifically created this form for the sole purpose of allowing attorneys and hearing representatives the opportunity to appeal the Tax Administrator's determination regarding employer tax. This notice must be returned to the Tribunal within 20 days of the date that the Tax Administrator's determination was mailed to the parties. Failure to return this notice on time will result in the appeal being dismissed.

When filling out this form, type or print answers neatly in the area provided. Attorneys and hearing representatives may attach additional documents, if needed.

QUESTION #1: Provide the name of the employer entering the appeal along with the employer's business, street address (or PO Box) and business telephone number (with area code) in the space provided. 

QUESTION #2: Provide the employer's account number.

QUESTION #3: Check the issue that indicates the basis of the appeal. More than one box may be checked. Attorneys and hearing representatives may attach additional documents, if needed.

QUESTION #4: Provide the name and title of the attorney or hearing representative requesting the subpoena along with the attorney or hearing representative's business, street address (or PO Box) and business telephone number (with area code) in the space provided.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this form, your request will then be denied. 

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the NOTICE OF APPEAL (TAX) to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. This form may also be faxed to the Tribunal at (402) 471-1734.