Request For Amusement Machine Stamps - Arkansas
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1Class Code 5501
STATE OF ARKANSAS
Department of Finance
REVENUE DIVISION
Miscellaneous Tax
and Administration
Post Office Box 896 - Room 2340
Joel Y. Ledbetter Building
Little Rock, Arkansas 72203
Phone: (501) 682-7187
Fax: (501) 682-1103
REQUEST FOR
AMUSEMENT MACHINE STAMPS
(Expires June 30th After Date Of Issue)
My current Year Permit Number is:
Name of Individual or Firm:
dba:
Business Phone
(
)
Mailing Address:
Emergency Phone (
)
(City)
(State)
(ZIP)
1. Amusement Stamps Requested ………………………………………………… ________ X $5.00 each = $ ____________
2. Carnival & Fair Amusement Stamps Requested ……… ________ X $5.00 each = $ ____________
3. Number of Stamp Penalties Issued ………………………………
________ X$10.00 each = $ ____________
4. Number of I.D. Decal Penalties Issued …………………
________ X$10.00 each = $ ____________
Total Amount Enclosed
……………………………………………………………………$
☺
NOTE:
Amusement Stamps are pro-rated at $2.50 between Jan thru June. (this does not apply to “renewal” or new accounts starting July 1)
For Stamps through
Fiscal June 30, 20
Amusement Machine Stamps Issued:
Carnival & Fair Stamps Issued:
Number Issued: ______________________________
Number Issued: ______________________________
From __________________ To __________________
From __________________ To __________________
If granted the stamps above , I agree to abide by the provisions of A.C.A. §26-57-401 et. seq., and conform to all rules and regulations
promulgated pursuant there to. I understand that these licenses are issued for the legal operation of coin operated Music and Amusement
machines as “Amusement Devices”, so state in Arkansas Code Ac a §26-57-401 et. Seq., and for no other purpose. I understand that these
licenses shall not insure the legality of operating equipment in a manner which may be considered inappropriate, illegal and or in violation of
Federal Code, Arkansas Code and/or City and County ordinances, rules and regulations.
Signature:
Signature:
Date:
INVESTIGATOR
OWNER / OPERATOR
Mail with remittance to above address or bring to the Ledbetter Building, 1816 West 7th Street, Little Rock, Arkansas
Class Code 5501
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