Form 04-169 - Coin-Operated Equipment Distributor'S Permit Application
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1
2MAIL ORIGINAL TO:
Coin-Operated Equipment
Permit Year
Alaska Department of Revenue
Income and Excise Audit Division
DISTRIBUTOR’S PERMIT APPLICATION
PO Box 110420
AS 43.35.030
Juneau, AK 99811-0420
(907) 465-4683
DUE DATE: This application is due before January 1 for the forthcoming calendar year, or prior to distributing coin-operated equipment.
A distributor of coin-operated equipment must pay an annual permit fee and file a Distributor’s Affidavit. A distributor means
a person who directly provides or furnishes a coin-operated device for operation on premises not owned by him and not under
his jurisdiction or control.
Individual or Corporation Name
Federal EIN or Soc. Sec. No.*
Daytime Telephone No.
* If your business has not been issued a federal employer identification number
Business Name
(EIN), you are required to provide your social security number so that the
Department of Revenue may administer the tax laws of Alaska. (AS 43.05.080)
The department uses the information for identification purposes.
Mailing Address
Is the applicant a corporation?
YES
NO
If yes, you must provide a signed, notarized affidavit from each
City, State, Zip Code
officer of the corporation.
Dept Use Only
1. Permit Fee ................................................................................................
1
$50.00
2. a. Penalty for late filing (5% per 30 day period, not to exceed 25%) ..........
2 a
b. Penalty for late payment (5% per 30 day period, not to exceed 25%) ....
2 b
3. Interest, per AS 43.05.225, is compounded quarterly at 11% per annum. ...
3
4. TOTAL DUE WITH THIS APPLICATION ............... Pay this amount
4
declare under penalty of unsworn falsification that this report, including all attachments, has been examined by me and to the
I
best of my knowledge and belief is true, correct, and complete.
Signature of Applicant
Date
Printed Name
Title
AFFIDAVIT INSTRUCTIONS: Each distributor must file an affidavit that he or she is a United States’ citizen and a bona
fide resident of Alaska for more than one year, and has never been convicted of a felony.
If the applicant is a partnership, each partner must submit an affidavit. If the applicant is a corporation, an affidavit is
required from each stockholder and employee of the corporation. Affidavits are printed on the other side of this form.
Attach additional sheets with affidavits if needed.
DEPT USE ONLY
PM5\04169
Form 04-169 (Rev. 12/95)
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