Carson City:
1150 E. William Street
Carson City, NV 89701-3109
(775) 684-6101
Fax (775) 684-6110
Las Vegas:
101 Convention Center Drive, Suite 250
Las Vegas, NV 89109
(702) 486-2600
Fax (702) 486-7206

Annual Revenue and Assessment Report Form
for Calendar Year
 

Company Name:  
Company Address:  
 
Telephone:  
Type of Utility:  

Preparer Name:  
Preparer Company:  
Address:  
 
Telephone:

Confirmation Email:  

1.

ASSESSABLE REVENUE: I/We the undersigned, under penalty prescribed in NRS 704.035, do hereby certify that total gross intrastate operating revenue as defined in NRS 704.033 and as contained in appropriate company ledgers for the above calendar year commencing January 1, 2011 and ending December 31, 2011 was:

ASSESSABLE REVENUE:
 
2.

ASSESSMENT: The assessment rate for this reporting period is 2.83 mills (0.00283). Your assessment for this year is the above ASSESSABLE REVENUE x 0.00283. The MINIMUM assessment is $100.

ASSESSMENT:
 
3.

PENALTY: The penalty for late payment (payment not made on or before August 1, 2012 is one (1) percent of the total unpaid balance for each month or portion thereof that the assessment is delinquent, or $10, whichever is greater, but no penalty may exceed $1,000 for each delinquent payment.

 PENALTY:
 
4.

AMOUNT DUE: Total of ASSESSMENT and PENALTY. This amount is due and payable on July 1, 2012 with penalties payable if paid after August 1, 2012. If the quarterly payment option is chosen, the first payment is due July 1, 2012 with subsequent payments due October 1, 2012, January 1, 2013, and April 1, 2013. If the assessment is paid late the appropriate penalty is to be included in the payment.

AMOUNT DUE:
  PAYMENT AMOUNT:

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