Nevada > Statewide > Nevada Gaming Commission And State Gaming Contol Board > Investigations Division
Personal Financial Questionnaire 5 - Nevada
| Personal Financial Questionnaire Form. This is a Nevada form and can be used in Investigations Division Nevada Gaming Commission And State Gaming Contol Board Statewide . |
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PERSONAL FINANCIAL QUESTIONNAIRE Name Address Date Submitted in connection with application for gaming license for: Name of Gaming Establishment 1. Do you anticipate active participation in the management and operation of the gambling establishment? Yes No If yes, attach detailed description of activity anticipated. 2. Amount to be invested in the business $ Percentage of ownership this will represent 3. Investment will be derived from the following sources: (Submit executed agreements for all financial transactions.) 4. Has your interest in this gambling establishment been assigned, pledged, or hypothecated to any person, firm, or corporation, or has any agreement been entered into whereby your interest is to be assigned, pledged, or sold either in part or in whole? Yes No 5. Have you ever filed bankruptcy? Yes No If yes, furnish details on separate sheet. 6. Have any individual, city, county, state, or Federal liens been filed against you as an individual, sole proprietor, No member of a partnership, owner of a corporation, or similar capacity? Yes If yes, provide details on separate sheet. 7. Has your Federal Income Tax Return ever been audited or adjusted? If yes, provide details on separate sheet. 8. Last Federal Income Tax Return was filed Yes No for year at City State Applicants are advised that Federal Income Tax Returns will be required during the licensing investigation. 1 of 10 Form 5_PFQ (Rev. 12/11) Applicant's Initials American LegalNet, Inc. www.FormsWorkFlow.com 9. Do you own or control any assets or liabilities located outside the United States? If yes, provide details on appropriate schedule or on a separate sheet. Yes No 10. Do you hold any assets in a Trust? Yes No If yes, attach a copy of all such trusts, and include a schedule of assets held by each trust. 11. Do you control, manage, or hold in trust any assets or liabilities for another person or entity? Provide details under remarks on page 5. 12. Annual Income $ Salary ....................................................................................................................... Interest ..................................................................................................................... Dividends ................................................................................................................. Other (Describe) Other (Describe) Other (Describe) ...................................... ...................................... ...................................... $ $ $ $ $ $ Yes No 13. List all assets and liabilities on the attached schedules. Please indicate all assets and liabilities held as sole and separate property by yourself and your spouse. (Attach additional schedules or forms if necessary.) 2 of 10 Applicant's Initials American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF ASSETS as of Date List all assets, both tangible and intangible, on the appropriate line below. Enter the amount as of the date of this statement. Each listed asset must be described fully on the appropriate schedule. Original Cost/ Investment $ ASSETS: Cash on Hand.............................................................................................. $ Cash in Financial Institutions (Schedule "A") .............................................. Accounts and Notes Receivable (Schedule "B") ......................................... Marketable Securities (Schedule "C") ......................................................... Business Investments (Schedule "D") ......................................................... Fixed Assets (Schedule "E") ........................................................................ OTHER ASSETS: (Schedule "F") .............................................................................................. TOTAL ASSETS ................................................................................................ $ Market Value $ 3 of 10 Applicant's Initials American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF LIABILITIES as of Date List all liabilities on the appropriate line below. Enter the amount as of the date of this statement. Each listed liability must be described fully on the appropriate schedule. LIABILITIES: Original Amount Present Balance $ Accounts Payable (credit cards, etc.) .......................................................... $ Taxes Payable ............................................................................................. Notes Payable (Schedule "G") .................................................................... Mortgages Payable (Schedule "H") ............................................................. Other Liabilities (Schedule "I") ..................................................................... TOTAL LIABILITIES ........................................................................................... $ $ NET WORTH .................................................................................................................................. $ CONTINGENT LIABILITIES (Schedule "J") .................................................................................... $ 4 of 10 Applicant's Initials American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ss. COUNTY OF I, Applicant's Name , being duly sworn, depose and say that the above statements are true and correct to the best of my knowledge and belief and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue a gaming license by a municipality, or by a county or by the State of Nevada. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements may be grounds for the revocation of a gaming license. Further, that I am voluntarily submitting this application under oath with full knowledge that the Gaming Control Act (NRS 463.140(5)) provides that "Any person making false oath in any matter before either the board or commission is guilty of perjury." I am voluntarily submitting this application under oath with full knowledge that I may be required to submit this application to appropriate municipal and county authorities charged by law with granting gaming licenses. APPLICANT Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public REMARKS 5 of 10 Applicant's Initials American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE "A" Cash in Financial Institutions
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