Application For Credit/refund Of Fees Paid On Mining Claims Form printable pdf download

Application For Credit/refund Of Fees Paid On Mining Claims Form

Nevada Department of Taxation

Application for Credit/Refund Of Fees Paid on Mining Claims

Return completed form to:

Department of Taxation

Division of Assessment Standards

1550 College Parkway Suite 115

Carson City, NV 89706

Or FAX to: 775-684-2020

Questions? Call the Department at (775) 684-2156 or 684-2100

STEP 1. Please provide your contact information:

Actual Payor of Claim Fees Entitled to Credit or Refund

Mailing Address of Payor

Owner of Claims registered by County Recorder – person or company

City

State

Zip Code

Relationship of Payor to Owner of Claims

Fax Number

(If avail.)

(Corporate Parent, Lessee, Agent, or other)

Daytime Telephone Number (with area code) of principal contact

E-mail address of Contact Person

STEP 2. Please provide information about the mining claim fees that were paid:

County Where Mining Claim Fees Were Paid

Amount of Mining Claim Fees Paid less Recording Fees

Date or Dates Paid

Affidavit Document Number

Number of Claims

Claim Names (Add additional page if necessary)

Please check one of the following: Did you:

(1) Pay the fee in full at the time of filing? ___________ OR (2) Make two payments? ____________

ATTACH “AFFIDAVIT AND DECLARATION OF CLAIMS HELD” AND A CANCELLED

CHECK OR THE RECEIPT FROM THE COUNTY AS PROOF OF PAYMENT.

STEP 3. SB 493, Section 16.7 provides that your claim may be handled as a credit to

any liability you may have on the Modified Business Tax (MBT) pursuant to NRS

363B.110. Please provide the following information regarding your MBT Account:

Are you registered for the Modified Business Tax? Yes ___________ No ______________

If yes, what is your Nevada Department of Taxation ID number? ______________________

STEP 4. Sign and date this form. Return to the address listed at the top of this form.

I hereby affirm the information on this form has been examined by me and to the best of my knowledge

and belief is a true, correct, and complete statement of the mining claim fees paid during the period

indicated.

________________________________

_______________________ ___________

SIGNATURE

TITLE

DATE

Revised App Form 8-30-11

Application For Credit/refund Of Fees Paid On Mining Claims Form

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