Form Otp-01 - Other Tobacco Products Excise Tax Return Page 6
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9AFFIDAVIT OF OTHER TOBACCO PRODUCTS WHOLESALE DEALER
An authorized officer of the Wholesale Dealer MUST sign this form and check the box below.
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-05
REVISED 01-01-08
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