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: 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, 2023 and ending December 31, 2023 was:
  ASSESSABLE REVENUE:

ASSESSMENT: The assessment rate for this reporting period is 3.31 mills (0.003310000). Your assessment for this year is the above ASSESSABLE REVENUE x 0.003310000. The MINIMUM assessment is $100.
ASSESSMENT:

LATE FEE: The Late Fee for late payment (payment not made on or before August 1, 2024 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 Late Fee may exceed $1,000 for each delinquent payment.
  LATE FEE:

AMOUNT DUE: Total of ASSESSMENT and LATE FEE. This amount is due and payable on July 1, 2024 with Late Fees payable if paid after August 1, 2024. If the quarterly payment option is chosen, the first payment is due July 1, 2024 with subsequent payments due October 1, 2024, January 1, 2025, and April 1, 2025. If the assessment is paid late the appropriate Late Fee is to be included in the payment.
AMOUNT DUE:
  PAYMENT AMOUNT: