Form Lt01 - Application For Certificate Of Compliance printable pdf download

Form Lt01 - Application For Certificate Of Compliance

NEVADA DEPARTMENT OF TAXATION

1550 E. COLLEGE PARKWAY STE. 115

CARSON CITY NV 89706

(775) 684-2125 or (775) 684-2126

APPLICATION FOR CERTIFICATE OF COMPLIANCE

SUBMIT $50.00 FEE FOR CURRENT FISCAL YEAR JULY 1 TO JUNE 30

ENCLOSE COPY OF FEDERAL BASIC PERMIT

DBA, if any:

Phone No:

Name of Company:

FEIN No:

Business Address:

Zip Code:

Mailing Address:

Zip Code:

Email Address:____________________________________________________________________________

The above named hereby applies to the Department of Taxation for a Certificate of Compliance, pursuant to Nevada Revised Statutes, Chapter 369.430.

Applicant is a: Corporation ( ) LLC ( ) Partnership ( ) Individual ( ) Other: _________________________

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 ( ) Rectifier ( ) Or the designated agent of one of these ( ) (copy of designation attached)

Distillers within the state of Nevada:

Applicant will be importing Liquor and/or Ethyl Alcohol to further refine: Yes ( ) No ( )

Pursuant to NRS 597.210 sections 1 and 2 effective May 1, 1975:

Applicant may not participate in a retail or wholesale business of alcoholic beverages in the state of Nevada as an owner, partner, or through a subsidiary, affiliate,

ownership equity or any other manner.

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.

The Department may contact you regarding possible additional licensing requirements.

Executed

day of

(City)

(State)

Signature:

(Owner, Partner or Officer)

Remember to submit a copy of your federal

basic permit and your check for the $50.00

fee with this completed application.