Form Lt 01 - Application For Certificate Of Compliance - Nevada Department Of Taxation 2004
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1NEVADA DEPARTMENT OF TAXATION
1550 E. COLLEGE PARKWAY STE. 115
CARSON CITY NV 89706
(775) 684-2122
APPLICATION FOR CERTIFICATE OF COMPLIANCE
SUBMIT $50.00 FEE FOR CURRENT FISCAL YEAR JULY 1 TO JUNE 30
DBA, if any:
Phone No:
Name of Company:
FEIN No:
Business Address:
Zip Code:
Mailing Address:
Zip Code:
The above named hereby applies to the Department of Taxation for a Certificate of Compliance, pursuant to
Nevada Revised Statutes, Chapter 369.430. ENCLOSE COPY OF FEDERAL BASIC PERMIT.
Applicant is a Corporation (
), Partnership (
), Individual (
)
Applicant will be selling to Nevada wholesalers (
)
Directly to Nevada consumers (
)
Owners, Partners or Officers:
Applicant is an Importer
, Brewer
, Distiller
, Manufacturer
,
Producer
, Vintner
, Bottler of Liquor
, or the designated agent of one
of these
(copy of designation attached).
Under NRS 597.210 and Sections 1 and 2, effective May 1, 1975:
Applicant is not engaged in the liquor business in the State of Nevada as an owner, partner or through a
subsidiary, affiliate, ownership equity or in any other manner. This covers the import/wholesale level as well
as the retail level.
Applicant promises if granted a Certificate of Compliance: (1) to faithfully comply with all laws of the State of
Nevada pertaining to the sale and shipping of liquors into Nevada and to comply with all rules and regulations of
the Department of Taxation; (2) to furnish the Department on or before the 10th of each month, an LTD 04 report
with copies of invoices, showing the quantity of liquor sold, shipped, or delivered to each licensed liquor
import/wholesaler or permittee in Nevada. Such reports shall state: (1) name and location/address of the Nevada
import/wholesaler or permittee to whom each shipment was made; and (2) invoice number, date and number of
packages or cases, and the breakdown in gallons by alcoholic percent content.
Executed
day of
20
at
,
(City)
(State)
Signature:
(Owner, Partner or Officer)
Remember to submit a copy of your federal
Date:________________Amt:_____________________
basic permit and your check for the $50.00
Ck No:______________________________
fee with this completed application.
Compliance Services: Power of attorney
Init:__________________
LT 01
2/04
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