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

Rail Safety Program Annual Assessment Report Form
Calendar Year 2010 
Company Name:  
Company Address:  
 
Telephone:  
Preparer Name:  
Preparer Company:  
Address:  
 
Telephone:
Confirmation Email:
1.

ASSESSABLE TONNAGE: The reported tonnage for the above calendar year commencing January 1, 2010 and ending December 31, 2010 was:
ASSESSABLE TONNAGE:
 
2.

ASSESSMENT: The assessment rate for this reporting period is 6.966 mills (0.006966). Your annual assessment for this year is the above ASSESSABLE TONNAGE x 0.006966.
ASSESSMENT:
 
3.

PENALTY: The penalty for late payment (payment not made on or before November 1, 2011 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 or before November 1, 2011 with penalties payable if paid after December 1, 2011.
AMOUNT DUE:
  PAYMENT AMOUNT: