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
Rail Safety Program Annual Assessment Report Form
Calendar Year 2022

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 TONNAGE: The reported tonnage for the above calendar year commencing January 1, 2022 and ending December 31, 2022 was:
ASSESSABLE TONNAGE:

ASSESSMENT: The assessment rate for this reporting period is 2.290 mills (0.002290). Your annual assessment for this year is the above ASSESSABLE TONNAGE x 0.002290.
ASSESSMENT:

LATE FEE: The Late Fee for late payment (payment not made on or before November 1, 2023 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 or before November 1, 2023 with penalties payable if paid after December 1, 2023.
AMOUNT DUE:
PAYMENT AMOUNT: