Form As 2914.1 B - Application For Amendments To The Merchant'S Registration Certificate Of A Commercial Location Page 2
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Form AS 2914.1 B
Rev. Sep 26 12
PART II – CEASE OF OPERATIONS
Indicate if you will cease to operate this location ............................................................................................................
Yes
No
(If you answered “No”, go to Part IV of this form. Otherwise, continue with this Part.)
Day
Month
Year
A.
Ceased operations effective date …..................................................................................................................
B.
Did you return the Merchant’s Registration Certificate together with Form AS 2914.1 B …............................
Yes
No
If you answered “No”, indicate the reasons for not returning it.
Day
Month
Year
Theft. Indicate date it was stolen ….................................................................................................
(Submit evidence of the complaint filed with the Puerto Rico Police Department.)
Day
Month
Year
Loss or Destruction. Indicate date it was lost …..........................................................................................
(Submit sworn statement indicating the reason for its loss or destruction.)
Other:_____________________________________________________________________
__________________________________________________________________________
C.
Did you return the Exemption Certificate together with Form AS 2914.1 B …............................................
Yes
No
Does not apply
If you answered “No”, indicate the reasons for not returning it.
Day
Month
Year
Theft. Indicate date it was stolen …..............................................................................................................
(Submit evidence of the complaint filed with the Puerto Rico Police Department.)
Day
Month
Year
Loss or Destruction. Indicate date it was lost ….........................................................................................
(Submit sworn statement indicating the reason for its loss or destruction.)
Other: ______________________________________________________________________
________________________________________________________________________
PART III – RETURN OF FISCAL TERMINALS
Indicate if Fiscal Terminals were installed in the points of sale of this location or if an existing application
was modified, in order to meet the requirements of the IVU Loto Oversight Program …...........................................
Yes
No
(If you answered “No”, go to Part IV of this form. Otherwise, continue with this Part.)
A.
Indicate the type of Fiscal Terminal that was installed in this location:
Certified Processor
Certified Auto Processor
Fiscal Terminal of the Department of the Treasury
B.
Confirmation number where you notify IVU Loto about the disconnection for ceased operations
..................
Amount of Fiscal Terminals that you will return because of ceased operations
C.
(Does not apply to certified processors) ….................................................................................................................
Indicate the Serial Number of each one of the Fiscal Terminals returned:
1.
(1)
(4)
(2)
(5)
(3)
(6)
2. Type (Model) of Fiscal Terminal returned:
TxPort Dial-Up that includes Phone Splitter, Phone Cable,
Network Cable and Power Supply.
TxPort Web Service that includes Network Cable and Power Supply.
T4210 Hypercom or equivalent by Dial-Up that includes Power Supply,
Phone Splitter and Phone Cable.
D. Indicate if you returned all the fiscal terminals of the Department of the Treasury that were installed in your location .............
Yes
No
N/A
E. Indicate if you returned all the collateral support systems (cables, splitters, etc.) of the fiscal terminals
of the Department of the Treasury …....................................................................................................................
Yes
No
N/A
If you answered “No” for items D and E, indicate the reasons for not returning the Terminals or
Day
Month
Year
the collateral support systems.
Theft. Indicate date it was stolen …..............................................................................................................
(Submit evidence of the complaint filed with the Puerto Rico Police Department.)
Day
Month
Year
Loss or Destruction. Indicate date it was lost ….......................................................................................
______________________________________________________
Explain:
Other: ______________________________________________________________________
Retention: Six (6) years.
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