Other Tobacco Products Excise Tax Return Form (Page 5 of 5) in pdf

Other Tobacco Products Excise Tax Return Form Page 5

TID & LOC:

AFFIDAVIT OF OTHER TOBACCO PRODUCTS WHOLESALE DEALER

An authorized officer of the Wholesale Dealer MUST sign this form and check the box below. This form MUST

be notarized each month.

Under penalty of perjury, I certify that the Wholesale Dealer submitting the attached Report, OTP-01

thru OTP-04 for the month of ______________, as of the date of this certification, is in full compliance

with all applicable sections of Chapter 370 of the Nevada Administrative Code, and Chapters 370 and

370A of the Nevada Revised Statutes.

This certification must be signed by a qualified officer authorized to bind the Wholesale Dealer. My position

with the Wholesale Dealer and my actual authority to certify on behalf of the Wholesale Dealer meets the

foregoing requirements.

I understand that the Nevada Department of Taxation may require additional information and/or documentation

relative to the matters reported herein.

I have examined this report, including attachments and supporting documents and, to the best of my

knowledge and belief, this Report, including attachments and supporting documents, is true, correct, and

complete.

By signing this affidavit on behalf of the Wholesale Dealer, I understand that the Wholesale Dealer is required

to comply with state and federal laws concerning the possession, distribution, and sale of tobacco products.

_______________________________________

____________________________________

Name of Wholesaler Dealer

Month/Year

________________________________________

____________________________________

Name of Officer of Wholesale Dealer (print name)

Report Prepared By

________________________________________

_____________________________________

Title

Telephone Number

________________________________________

_____________________________________

Signature of Officer

Fax Number

OTP-03 Instructions

REVISED 03-01-11

Other Tobacco Products Excise Tax Return Form Page 5