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Annual License Fee Report For The Issuance Or Renewal Of A Distributors License NGC-21D - Nevada
| Annual License Fee Report For The Issuance Or Renewal Of A Distributors License Form. This is a Nevada form and can be used in Tax And License Division Nevada Gaming Commission And State Gaming Contol Board Statewide . |
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NGC-21D (08-16-11) NEVADA GAMING COMMISSION ANNUAL LICENSE FEE REPORT for the issuance or renewal of a DISTRIBUTOR'S LICENSE This report, together with your remittance payable to the order of the NEVADA GAMING COMMISSION, is required to be filed PRIOR to the issuance of a new license; PRIOR to the commencement of operations; and ON or BEFORE December 31 for the ensuing calendar year. For Calendar Year Account No., Name, Address, Zip Code Filing Deadline: For Office Use Only Check Number Batch Number Entry Date Please correct if in error INSTRUCTIONS A. This form is for the use of DISTRIBUTORS of GAMING DEVICES only. B. All licenses shall be issued for the calendar year beginning January 1 (and expiring December 31), and regardless of the date of application or date of issuance of the license, the fees to be charged and collected under the provisions of NRS 463.660 shall be those fees fixed as an annual license fee for distributors of gaming devices. C. For the issuance or renewal of a seller's or distributor's license the commission shall charge and collect from each applicant -- $500. PLEASE COMPLETE THE FOLLOWING: 1. Application for the issuance or renewal of a distributor's license ($500) 2. Penalty for Late Payment ($125) NRS 463.270(5) 3. REMITTANCE DUE (Total of Line 1 and Line 2 above) $ $ Please make remittance payable to: NEVADA GAMING COMMISSION Return to the State Gaming Control Board, PO Box 8004, Carson City, NV 89702-8004 Pursuant to NRS 353.1467, payments made to the State, in the aggregate, that amount to $10,000.00 or more must be sent electronically. INDICATE IN THE SPACE PROVIDED BELOW THE TYPE OR TYPES OF EQUIPMENT, MATERIAL, DEVICE OR MACHINE TO BE DISTRIBUTED: I, (Owner, Partner, President, Treasurer, Other-describe) , certify and declare under the penalties of perjury that I am the of the business named above; that this is a true, correct and complete report to the best of my knowledge, information, and belief; and that this application and report is made with the knowledge and consent of all other individuals licensed. Dated Person to contact regarding this report: Name: Signed Phone: American LegalNet, Inc. www.FormsWorkFlow.com RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS
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