School Readiness Tax Credit Act –
Staff Member Application
8-770-2021
Applicant Name and Address Eligible Program Name and Address
Applicant’s Name Eligible Program Name
Street or Other Mailing Address Street or Other Mailing Address
City State Zip Code City State Zip Code
Applicant’s Social Security Number (SSN) Dates of employment with the above eligible program. (If employed by more than one eligible program, attach additional documentation.)
From: To:
Below, please check the box that applies to your Nebraska Early Childhood Professional Records System classification
level as shown on the Attestation of Staff Member Classification Level form. You must attach the Attestation of
Staff Member Classification Level form to this application.
Level Tax Credit
Check the
Level that
Applies
One $540
Two $810
Three $1,350
Four $1,620
sign
here
Signature of Applicant Date Phone Number
Email Address
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.
Instructions
Who May File. An eligible staff member may le this application. An eligible staff member is an individual that:
• Is employed by eligible program for at least six months of the tax year; or
• Is a self-employed individual for an eligible program for at least six months of the tax year; and
• Provided child care and early childhood education for the eligible program; and
• Is assigned a classication level in the Nebraska Early Childhood Professional Record System.
An eligible program is one that has been assigned a quality scale rating under the Step Up to Quality Child Care Act.
An eligible staff member does not include certied teaching and administrative staff employed by before-and after-
school or pre-kindergarten programs established by school boards or educational service units.
When to File. This application for credits must be led after you have been providing child care and early childhood
education for an eligible program for at least six months of the taxable year.
What to File. Attach and submit a signed School Readiness Tax Credit Act—Attestation of Staff Member
Classication Level along with this application.
Specific Instructions
Applicant Information. Enter your name, mailing address, and SSN.
Eligible Program Information. Enter the name and address of the eligible program.
Dates of Employment. Enter the dates you were employed by, or self-employed with the eligible program. If you
were employed by more than one eligible program, attach a list of additional employers. Be sure to include the name,
address, and dates of employment for each additional employer.
Mail this Application and your Attestation form to:
Nebraska Department of Revenue, PO Box 94609, Lincoln, NE 68509-4609.
2021
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Identify Classification. Place an “X” next to the most recent level you have been assigned on the Nebraska Early
Childhood Professional Record System.
Signature. This application must be signed by the eligible staff member. Include a daytime phone number in case
the Nebraska Department of Revenue (DOR) needs to contact you about the application. By entering an email
address, the taxpayer acknowledges that DOR may contact the taxpayer by email. The taxpayer accepts any risk to
condentiality associated with this method of communication. DOR will send all condential information by secure
email or the State of Nebraska’s le share system.
Additional Instructions
Application and Approval Steps.
1. Request the School Readiness Tax Credit Act — Attestation of Staff Member Classication Level form
from the Nebraska Department of Education. Please allow six weeks for your request to be processed by the
Nebraska Department of Education.
2. Attach your School Readiness Tax Credit Act — Attestation of Staff Member Classication Level form to
this application and le it with DOR by March 1 of the year following the taxable year for which you plan
to claim this credit.
DOR will process the applications in the order received until the program tax credit limitation of $5 million
has been reached. Please allow four weeks for DOR to process and respond to your application.
3. Claim your tax credit by attaching the tax credit certication from the DOR to your Individual Income Tax
Return, Form 1040N.
