Carson City:
1150 E. William Street
Carson City, NV 89701-3109
(775) 684-6101
Fax (775) 684-6110 		Las Vegas:
9075 West Diablo Drive, Suite 250
Las Vegas, NV 89148
(702) 486-7210
Fax (702) 486-7206

Annual Revenue and Assessment Report Form
for Calendar Year

CPC or CMRS #:
Company Name:
Company Address1:
Company Address2:
Company City:   State:  Zip:
Company Telephone:
Type of Utility:
Preparer First Name:    Last Name:  
Confirmation Email:
   
Preparer Company:
Preparer Address1:
Preparer Address2:
Preparer City:  State:  Zip:
Preparer Telephone:

  
  ASSESSABLE REVENUE:

ASSESSMENT:

  LATE FEE:

AMOUNT DUE:
  PAYMENT AMOUNT: