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 Gas Alternative Seller Annual Revenue and Licensing Fee Report Form for Calendar Year 2022 2021 CPC or CMRS #: AlphanumOnly No , Company Name: Required AlphanumOnly No , Company Address1: Required AlphanumOnly No , Company Address2: AlphanumOnly No , Company City:   State: Nevada Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  Zip: CityRequired StateRequired ZipRequired Company Telephone: Required Invaild Format Type of Utility: Electric / GAS Railroad Telecommunications Water / Sewer / Waste * Preparer First Name:  * Last Name: * AlphanumOnly AlphanumOnly Confirmation Email: Invalid Format Required   Use Company Address Information Above   Preparer Company: AlphanumOnly No , Required Preparer Address1: AlphanumOnly Required Preparer Address2: AlphanumOnly No , Preparer City:  State: Nevada Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming  Zip: CityRequired StateRequired ZipRequired Preparer Telephone: TelephoneRequired Invaild Format ANNUAL PAYMENT QUARTERLY PAYMENT ASSESSABLE REVENUE: I/We the undersigned, under penalty prescribed in NAC 704.79555, do hereby certify that total gross revenue derived from sales related to services provided pursuant to the license of the alternative seller as defined in NAC 704.79553 and as contained in appropriate company ledgers for the above calendar year commencing January 1, 2022 and ending December 31, 2022 was: * * * ASSESSABLE REVENUE: LICENSING FEE: The licensing fee rate for this reporting period is 3.03 mills (0.00303). Your annual licensing fee for this year is the above ASSESSABLE REVENUE x 0.00303. The MINIMUM licensing fee is $100. LICENSING FEE: LATE FEE: The Late Fee for late payment (payment not made on or before August 1, 2023 is one (1) percent of the total unpaid balance for each month or portion thereof that the fee is delinquent, or $10, whichever is greater, but no Late Fee may exceed $1,000 for each delinquent payment. * LATE FEE: CREDIT: Fees paid to a public utility or another alternative seller for services purchased for intrastate resale for the calendar year commencing January 1, 2022 and ending December 31, 2022 was: * CREDIT: AMOUNT DUE: Total of LICENSING FEE and LATE FEE MINUS ANY CREDITS DUE. This amount is due and payable on July 1, 2023 with penalties payable if paid after August 1, 2023. If the quarterly payment option is chosen, the first payment is due July 1, 2023 with subsequent payments due October 1, 2023, January 1, 2024, and April 1, 2024. If the licensing fee is paid late the appropriate Late Fee is to be included in the payment. AMOUNT DUE: * * PAYMENT AMOUNT: