Annual Certication for the
Volunteer Emergency Responders Incentive Act
To be completed by a conrmed and approved Certication Administrator for certication years 2019 and after.
Include only those volunteer members who have earned 50 or more points during the calendar year (see instructions).
Identify the Nebraska County, City, Village, or Rural or Suburban Fire Protection District the Volunteer Department Serves Calendar Year
Identify the Volunteer Department for Which This Certication is Being Provided
8-803-2017 Rev. 02-2024
Supersedes 8-803-2017 Rev. 11-2021
Address
Last Four Digits of Points Earned
Social Security Number this Calendar Year
I hereby certify and declare under penalties of law that the individuals listed above (and on attached lists, if necessary) have met the
minimum requirements (50 points or more) for the listed calendar year and have qualied as active members of the volunteer emergency
responder unit, rescue squad unit, or reghter unit identied above, and were not paid an hourly wage for their emergency responder
duties.
Sign and submit this certication to the Volunteer Emergency Responders
web page at revenue.nebraska.gov or mail to:
Nebraska Department of Revenue, PO Box 94609, Lincoln, NE 68509-4609.
sign
here
Signature of Conrmed and Approved Certication Administrator Date Daytime Phone
Printed Name Email Address
Legal Name of
Qualied Volunteer Member
Checking this box veries that all volunteer members included on this annual certication were not paid an hourly wage for their
volunteer responder duties.
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Instructions
Who Must File. This annual certication must be signed and led by a certication administrator conrmed and
approved by a Nebraska county, city, village, or rural or suburban re protection district (governing body). The
certication documents the active service of the volunteer emergency responders, rescue squad members, or reghters
who have met the minimum requirements for receiving an income tax credit under the Volunteer Emergency Responders
Incentive Act (Act).
When and Where to File. This annual certication must be led no later than February 15 following the year of
certication. Upload a signed copy to the Volunteer Emergency Responders web page or mail to the Nebraska
Department of Revenue (DOR):
• Upload to Volunteer Emergency Responders web page at revenue.nebraska.gov; or
• Mail to the Nebraska Department of Revenue, PO Box 94609, Lincoln, NE 68509-4609.
Certication administrators who upload the annual certication using this secure method of submission will receive
an email conrmation that may be kept with your records as proof your document was received by the DOR.
Properly Completed Annual Certication. DOR will only accept annual certications completed with the required
information and led by February 15. Incomplete annual certications will be returned to the certication administrator
for correction. The corrected annual certication must be reled with DOR within 60 days of its return, or individual
volunteer members will be ineligible to claim the $250 credit on their Nebraska Individual Income Tax Return, Form
1040N.
Checkbox Verifying that Volunteer Members are Not Paid an Hourly Wage. The certication administrators
signing this form must verify by checking the box that the volunteer members are not paid an hourly wage for attending
training or responding to calls. Volunteer members who receive an hourly wage for these activities lose their volunteer
status and are not eligible for the credit. Volunteer members who receive reimbursement for expenses, reasonable
benets, or a stipend for attending training or responding to service calls do not lose their volunteer status and remain
eligible for the credit.
Claiming the Credit. Any volunteer member who has been certied for at least two years by either a volunteer
department’s governing body (2016, 2017, 2018) or by a volunteer department’s certication administrator (2019 or
later) as meeting the qualications of the Act may claim a $250 refundable credit on his or her Form 1040N. The credit
will only be allowed after the individual is certied for at least two years by a Nebraska governing body or certication
administrator as meeting the requirements of the Act and their name is included on a timely led annual certication
submitted to DOR. Volunteer members who have met the two-year certication requirement may claim a $250 credit
on the Form 1040N for each year they earn 50 points or more during a calendar year.
Example 1. An individual listed as qualied on a properly completed annual certication form or other
documentation issued by a Nebraska governing body and received by DOR for both the 2017 and 2018
calendar years may begin claiming the credit on his or her 2018 Form1040N.
Example 2. An individual listed as qualied on a properly completed annual certication form or other
documentation issued by a Nebraska governing body and received timely by DOR for 2017, but who was
not listed on the 2018 annual certication form, may not claim the credit on his or her 2018 Form1040N.
However, if this individual is listed as a qualied individual on a 2019 properly completed annual certication
form or other documentation issued by a Nebraska certication administrator and received timely by DOR
for 2019, the credit may be claimed on the individual’s 2019 Form1040N. The initial two qualifying years do
not need to be consecutive. A volunteer member may claim the refundable income tax credit beginning with
the second service year in which the qualied volunteer member was included on an annual certication and
every year after that they qualify.
Accumulating Points. Volunteer members may earn points by participating in the activities as described below.
Twenty-ve points for responding to 10% of the emergency response calls which are dispatched from his or her assigned
station or company during a year of service and which are relevant to the duty category of the individual.
A maximum of 25 points for participating in training courses as follows:
• Courses under 20 hours duration, one point will be awarded per two hours in the course, with a maximum of
ve points awarded per course;
• Courses of 20 to 40 hours in duration, ve points will be awarded, plus one point awarded for each hour after
the rst 20 hours in the course, with a maximum of ten points awarded per course; and
• Courses over 40 hours duration, 15 points will be awarded per course.
One point for participating in each drill, with a maximum total of 20 points. Each drill must last at least two hours.
Drill means regular monthly drills used for instructional and educational purposes, as well as mock emergency response
exercises to evaluate the efciency or performance by the personnel of a volunteer department.
One point per meeting for attending an ofcial meeting of the volunteer department or mutual aid organization, with
a maximum total of not more than ten points.
Ten points for completing a term in one of the following:
• An elected or appointed position dened in the volunteer department's constitution or bylaws;
• An elected or appointed position for a mutual aid organization; or
• An elected ofce of the Nebraska State Volunteer Fireghters Association, the Nebraska Emergency Medical
Services Association, or other organized associations dealing with emergency response services in Nebraska.
One point per activity, but no more than one point per day, with a maximum total of no more than ten points, for:
• Participating in activities of re prevention communicated to the public at open houses or speaking engagements
on behalf of the volunteer department;
• Presenting re or rescue equipment at a parade or other public event;
• Attending the Nebraska State Volunteer Fireghters Association annual meeting;
• Attending the Nebraska Emergency Medical Services Association annual meeting;
• Attending a meeting of a governing body of a county, city, village, or rural or suburban re protection district
on behalf of the volunteer department; or
• Other activities related to emergency services as approved by the county, city, village, or rural or suburban
re protectiondistrict.
Activities that qualify a person to receive points in more than one of the categories can only be credited to one category.
Signature. This annual certication must be signed by a certication administrator who was conrmed and approved
by the volunteer department’s governing body.
Email. By entering an email address, the certication administrator acknowledges that DOR may contact the certication
administrator by email. The certication administrator accepts any risk to condentiality associated with this method
of communication. DOR will send all condential information by secure email or the State of Nebraska’s le share
system. If you do not wish to be contacted by email, write “Opt Out” on the line labeled “email address.”