Sd Eform-0870 V2 - South Dakota Application To Register Amusement Machines
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SD EForm -
0870 V2
HELP
South Dakota Application to Register Amusement Machines
for the year ending
, 20
June 30th
1. Owner / Operator Name - Enter individual’s name, partnership or corporation
2. Business / Trade Name - If different than above
3. Mailing Address of Business
3a. Phone Number
4. Location Address of Business - If different than above
5. Type of Ownership
Sole Proprietorship
Partnership
Corporation
6. Identify partners or corporate officers
Name
Address
City
State
Zip
Title
Calculation of Tax Due
7. List municipalities where machines are located and the number of machines in each municipality. Attach extra
sheets if necessary.
A. City
B. Number of Machines x $12.00
=
C. Fee
$0.00
$0.00
$0.00
$0.00
8. Total from machines located within a municipality
9. Number of machines NOT located within a municipality
x$12.00
$0.00
$0.00
10. TOTAL DUE (add lines 8 & 9 and remit this amount)
11.
I certify that none of the machines being registered are quarter pushers or illegal games of chance (see reverse)
12. I swear, under penalty of perjury, that the statements contained in this application and any attached schedules are
true, accurate, and correct.
Signature
Title
Date
If you no longer own amusement machines, please return this form marked NONE and advise this office of any new owner(s)
New Owner
Address
Date
PRINT FOR MAILING
CLEAR FORM
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