Fillable Form 0405-095 - Pull-Tab Manufacturers Sworn Statement printable pdf download

Form 0405-095 - Pull-Tab Manufacturers Sworn Statement

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Alaska

095

Pull-Tab Manufacturers Sworn Statement

BEFORE THE DEPARTMENT OF REVENUE

STATE OF ALASKA

In Re:

(Name of License Applicant)

Sworn Statement

, the

of the applicant in this

matter, acting individually and on behalf of, and with the express authority of, such applicant, do affirm the following:

1. Applicant is applying to the Alaska Department of Revenue for an Alaska pull-tab manufacturer’s license as required

by AS 05.15.181.

2. The Applicant acknowledges that 15 AAC 160.370 and 15 AAC 160.390 require that pull-tabs and pull-tab series

that are manufactured, sold, or distributed in Alaska must, inter alia, comply with the standards established by the

North American Gaming Regulators Association (“NAGRA”), as amended (

cfm?an=4 and click on Approved NAGRA Pulltab Standards).

3. This sworn statement, given under the penalty of perjury, attests that the pull-tabs and pull-tab series that the

Applicant will manufacture, sell, or distribute in Alaska in the period to be covered by the license, fully comply in all

material respects with the standards established by NAGRA.

4. This attestation is made based upon actual knowledge or examination sufficient to enable me herein to affirm

compliance.

(Name of License Applicant)

By:

Printed Name:

Title:

SUBSCRIBED AND SWORN to or affirmed before me at

, on this

day of

, 20

Notary Public

My Commission Expires:

Phone 907-465-2320

Fax 907-465-6495

095

Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420

0405-095 Rev 04/22/13

Form 0405-095 - Pull-Tab Manufacturers Sworn Statement

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