Personal Financial Questionnaire {5} | Pdf Fpdf Docx | Nevada

 Nevada /  Statewide /  Nevada Gaming Commission And State Gaming Contol Board /  Investigations Division /
Personal Financial Questionnaire {5} | Pdf Fpdf Docx | Nevada

Personal Financial Questionnaire {5}

This is a Nevada form that can be used for Investigations Division within Statewide, Nevada Gaming Commission And State Gaming Contol Board.

Alternate TextLast updated: 4/9/2019

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Form 5 Personal Financial Questionnaire (Rev. 03/18) 1 of 10 PERSONAL FINANCIAL QUESTIONNAIRE Date Full Name Last First M.I. Address Street Address Apartment/Unit # City State ZIP Code Phone Email 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, member of a partnership, owner of a corporation, or similar capacity? Yes No If yes, provide details on separate sheet. 7. Has your Federal Income Tax Return ever been audited or adjusted? Yes No If yes, provide details on separate sheet. 8. Last Federal Income Tax Return was filed for year at City State Applicants are advised that Federal Income Tax Returns will be required during the licensing investigation. American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 2 of 10 9. Do you own or control any assets or liabilities located outside the United States? Yes No If yes, provide details on appropriate schedule or on a separate sheet. 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? Yes No Provide details under remarks on page 5. 12. Annual Income $ Salary ....................................................................................................................... $ Interest ..................................................................................................................... $ Dividends ................................................................................................................. $ Other (Describe) ...................................... $ Other (Describe) ...................................... $ Other (Describe) ...................................... $ 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.) American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 3 of 10 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/ ASSETS: Investment Market Value Cash on Hand .............................................................................................. $ $ .............................................. ......................................... Marketable Securities ......................................................... ......................................................... ........................................................................ OTHER ASSETS: .............................................................................................. TOTAL ASSETS ................................................................................................ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 4 of 10 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 ............................................................................................. .................................................................... ............................................................. ..................................................................... TOTAL LIABILITIES ........................................................................................... $ $ NET WORTH .................................................................................................................................. $ CONTINGENT LIABILI .................................................................................... $ American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 5 of 10 STATE OF ss. COUNTY OF I, , 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 tknowledge 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 American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 6 of 10 Cash in Financial Institutions List below all accounts, foreign or domestic, maintained by you, your spouse, or dependent children. Name and Address of Financial Institution Names of Persons Appearing on Account Account No. Date Opened Interest Rate Type of Account Balance as of (Date) Accounts and Notes Receivable List below all accounts and notes receivable held by you, your spouse, or dependent children. Indicate by means of an asterisk (*) in the first column accounts and notes receivable held by your spouse and/or dependent children. Name and Address of Debtor Date Incurred Original Amount Unpaid Balance Payment/ Period Interest Rate Maturity Date Purpose Collateral American LegalNet, Inc. www.FormsWorkFlow.com Form 5 Personal Financial Questionnaire (Rev. 03/18) 7 of 10 Marketable Securities List below the information requested for all marketable securities held or controlled by you, your souse, or dependent children. Whenever interest exists through a mutual fund or holding company, the stocks held by such mutual fund or holding company need not be listed; whenever such interest exists through a beneficial interest in a trust, the stocks and bonds held in such trust shall be listed if you, your spouse, or dependent children have knowledge of what stocks and bonds are so held. INDICATE PUBLICLY TRADED STOCKS AND BONDS BY AN ASTERISK (*). Indicate by means of a double asterisk (**) next to the first column all stocks and bonds held by your spouse or dependent children. Issuer Type No. of Shares or Units Purchase Price Date of Purchase Name in Which Held Market Value Business Investments List below the information requested regarding any business investments in which any direct, indirect, vested, or contingent interest is held by you, your spouse, or dependent children, along with the names of all individuals or entities who share a direct, indirect, vested, or contingent interest therein. This should include bu

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