Certificate No.: 002- CONSUMER USE TAX RETURN - Nevada

Nevada department OF TAXATIONC ertificate No.: 002- CONSUMER USE TAX RETURNFor department Use OnlyMail Original To: Nevada department of taxation PO Box 7165 San Francisco, CA 94120-7165 Due on or before:For Quarterending:A RETURN MUST BE FILED EVEN IF no tax LIABILITY EXISTSENTER AMOUNTS IN COUNTY OF USEAMOUNT SUBJECT TO USE TAX TAX RATECALCULATED TAXTAX CALCULATION FORMULACOLUMN AX COLUMN B= COLUMN C 01 CHURCHILL 02 CLARK 03 DOUGLAS 04 ELKO 05 ESMERALDA 06 EUREKA 07 HUMBOLDT 08 LANDER 09 LINCOLN 10 LYON 11 MINERAL 12 NYE 13 CARSON CITY 14 PERSHING 15 STOREY 16 WASHOE 17 WHITE PINETOTALS18. 19. 20. 21. 22. CHECKS PAYABLE TO Nevada department OF TAXATIONCONSUMER USE TAX RETURN 12/09/15I HEREBY CERTIFY THAT THIS RETURN INCLUDING ANY ACCOMPANYING SCHEDULE AND STATEMENTS HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COMPLETE MUST BE SIGNED_____SIGNATURE OF TAXPAYER OR AUTH.

NEVADA DEPARTMENT OF TAXATION Certificate No.: 002-CONSUMER USE TAX RETURN For Department Use Only Mail Original To: Nevada Department of Taxation PO Box 7165 San Francisco, CA 94120-7165 Due on or before: For Quarter ending: A RETURN MUST BE FILED EVEN IF NO TAX LIABILITY EXISTS ENTER AMOUNTS IN

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