Form Spt 801 - South Dakota Application To Register Special Amusement Machines
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2SD EForm -
Complete and use the button at the end to print for mailing.
1323 V2
South Dakota Application to Register Special Amusement Machines
HELP
(Antique Machines or Machines used only at Fairs)
for the period ending
, 20
June 30th
Owner Name:
Business Name:
Business Address:
Mailing Address:
City:
State:
Zip:
Type of Ownership:
Sole Prop.
Partnership
Corporation
Identify partners or corporate officers:
NOTE: This form applies ONLY to Antique Machines (machines manufactured before 1940) or machines used exclusively at
Government Sponsored FAIRS (see instructions)
ANTIQUE MACHINES
Number of Machines registered (NO FEE is due for antique machines):
DEVICES USED SOLELY AT FAIRS
1. List municipalities where machines are located and the number of machines in each municipality (attach
additional sheets if needed)
A. City
B. Number of Machines x $3.00
C. Fee
$0.00
$0.00
$0.00
2. Totaly from machines located within a municipality
$0.00
3. Number of machines NOT located within a municipality
x$3.00
$0.00
4. TOTAL DUE (add lines 2 and 3 and remit this ammount)
$0.00
5. Specify period machines will be in service (30 consecutive days)
Beginning date:
Ending date:
I certify that NONE of the machines being registered are quarter pushers or other illegal games of chance (see reverse).
I swear under penalty of perjury, that this information is true, correct, and complete.
Signature:
Date:
SPT 801
Please Read Reverse Side of this Form
1.
PRINT FOR MAILING
CLEAR FORM
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