Form Otp 01 - Other Tobacco Products (Otp) Excise Tax Return Page 3

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NEVADA DEPARTMENT OF TAXATION
1550 East College Parkway, Room #115
Carson City, Nevada 89706
(775) 687-6483
READ INSTRUCTIONS ON THE REVERSE SIDE OF THIS REPORT BEFORE PREPARING
Pursuant NRS 370A
For the Month of
"ROLL-YOUR-OWN" TOBACCO REPORT
(month/year)
(If additional space is needed, please photocopy the report before making entries)
OTP License No. __________________________
Wholesaler ______________________________
( A )
( B )
( C )
( D )
Name and Address of First Importer of Foreign Produced
Non-Participating Manufacturer Name and Address
Tobacco
Brand Name
Ounces of "Roll -Your- Own" Tobacco Sold in Nevada
( E ) I
CERTIFY THAT THE WHOLESALE DEALER THAT I AM PREPARING AND FILING THIS REPORT FOR
(CHECK 1, 2, OR 3)
1.
The wholesale dealer is not a manufacturer of tobacco products as defined in NRS 370A.060.
2.
If the wholesale dealer is a manufacturer of tobacco products, has been in compliance with NRS 370A.140 and 370A.160(1) at all applicable times since May 24, 1999.
3.
If the wholesale dealer is a manufacturer of tobacco products and was not in compliance with NRS 370A.140 or 370A.160(1), has been brought into compliance with those sections of law.
AND (CHECK 1 OR 2)
1.
The wholesale dealer is not owned in whole or in part by a manufacturer of tobacco products as defined in NRS 370A.060.
2.
The wholesale dealer is owned in whole or in part by one or more manufacturers of tobacco products as defined in NRS 370A.060. The name and address of each such manufacturer is listed in
the space below. Each manufacturer of tobacco products listed has been and is in compliance with NRS 370A.140 and 370A.160(1) at any time it applied to the manufacturer.
( F )
SIGNATURE
DATE

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