Nevada Department of Taxation 1550 East College Parkway Carson City NV 89706 Form LTD 7 04/03 STATE OF NEVADA DEPARTMENT OF TAXATION REQUEST AND CERTIFICATION FOR INTERCOMPANY LIQUOR TRANSFER In accordance with the provisions of the Nevada Revised Statute, Chapter 369.4865, the undersigned hereby applies for approval to transfer liquor, other than beer, from a retail liquor store with a valid, non-restricted gaming license, to an affiliate retail liquor store with a valid, non-restricted gaming license. Attach required documentation before submitting to the Department of Taxation. See instructions. Original Location Company Name:_________________________________ Contact Name:____________________________________ Doing business as:________________________________ Address:_______________________________________ Phone:__________________ Fax:____________________ Non-Restricted Gaming License Number:______________ - _____ Recipient Location Company Name:_________________________________ Contact Name:____________________________________ Doing business as:________________________________ Address:_______________________________________ Phone:__________________ Fax:____________________ Non-Restricted Gaming License Number:______________ - _____ Description of Liquor to be transferred: NAME OF PRODUCT QUANTITY SIZE ALCOHOL % TOTAL GALLONS DATE PURCHASED Attach additional sheets if necessary The undersigned requests approval to transfer liquor, other than beer, herein described, on___________________ Date(s) The foregoing statements, and attached declarations, are true and correct to the best of the knowledge of the undersigned. Undersigned must represent the respective companies as officers or directors. Original Location Licensee: Recipient Location Licensee: By:______________________________________ By:______________________________________ Title:_____________________________________ Title:_____________________________________ Date:____________________________________ Date:____________________________________ Approved by the Nevada Department of Taxation: By:______________________________________ Date:______________________________________ Title:____________________________________ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR REQUEST AND CERTIFICATION FOR INTERCOMPANY LIQUOR TRANSFER ORIGINAL LOCATION: Print the company name, doing business as name, and address of company currently in possession of the liquor to be transferred. Print a name, phone number and fax number of the contact person for the originating company. Include the non-restricted gaming license number of originating company. RECIPIENT LOCATION: Print the company name, doing business as name and address of company receiving the liquor. Print a name, phone number and fax number of the contact person for the recipient company. Include the non-restricted gaming license number of recipient company. NAME OF PRODUCT: List the brand name and type of liquor, other than beer, to be transferred. i.e.; John Doe’s Cabernet Sauvignon. QUANTITY: List the number of packages of the brand name and type of liquor to be transferred. SIZE: List the size of the package of the liquor to be transferred. i.e.: 750 ML, 1 Liter. ALCOHOL %: List the percentage of alcohol by content of the liquor to be transferred. TOTAL GALLONS: Calculate the total gallons of liquor to be transferred. Use the following formula to convert milliliters to gallons: Quantity times Size = total milliliters Divide total milliliters by 1000 = total liters Multiply total liters by .26417 for wine or .264172 for distilled spirits = total gallons Example: 12 bottles x 750 ML= 9000/1000= 9 liters x .26417= 2.37753 or 2.38 gallons. DATE PURCHASED: List the date of original purchase of liquor from Nevada licensed wholesaler. List the date(s) you are requesting to transfer liquor. Transfer must be completed on the date(s) listed on the Request and Certification for Intercompany Liquor Transfer form. If transfer cannot be completed on the date(s) approved by the Department, a new request will need to be submitted. An authorized representative of the originating company and an authorized representative of the recipient company must sign the Request and Certification for Intercompany Liquor Transfer. The following documents must be included with request in order to obtain approval: 1. Copy of non-restricted gaming license from both affiliates 2. Copy of retail liquor license from both affiliates 3. Evidence of affiliation between the locations transferring liquor (Document from Secretary of State or notarized statement from company official) 4. Legible copies of invoices of original purchase of liquor from Nevada licensed wholesaler 5. An affidavit from each Nevada licensed wholesaler attesting to their marketing area Request and Certification for Intercompany Liquor Transfer form and all pertinent documents listed above, must be received by the Department of Taxation 30 days prior to the date of transfer. The approved transfer request, signed by the Department of Taxation, must accompany the liquor during transfer. Copies of the approved request must be maintained by both the originated company and the recipient company. Send completed form and pertinent documents to: Nevada Department of Taxation 1550 E. College Pkwy, Suite 115 Carson City, NV 89706 American LegalNet, Inc. www.FormsWorkflow.com