SI-10 (Revised 09/2018)
Central Services Division
Vehicle Programs
555 Wright Way
Carson City, Nevada 89711
(775) 684-4491
Email: DMVSelfInsurance@dmv.nv.gov
CERTIFIED PUBLIC ACCOUNTANT’S
AFFIDAVIT OF AUDIT AND CURRENT FINANCIAL RATIO
Self-Insurance Applicant:
Name of Nevada Certified Public Accounting Firm:
Nevada Certified Public Accountant (CPA) License Number:
CPA’s Address:
CPA’s Telephone Number:
Required Financial Ratio information:
Total Current Assets: $
Total Current Liabilities: $
Current Financial Ratio: %
I, the undersigned, being duly sworn, attest the financial statements of the above-mentioned
Self-Insurance Applicant,_______________________________________, have been audited.
NOTE: TO BE SIGNED BY A NEVADA LICENSED CERTIFIED PUBLIC ACCOUNTANT ONLY (NAC 485.060).
CPA’s Printed Name
Signature
Date
NOTARIZATION:
State of , County of
I certify that on the date set forth below, the individual named above did appear
personally before me and that I did identify this individual. The statements on
this document are subscribed and sworn to before me by the endorsee on this
day of , .
Notary Public Signature:
My Commission Expires:
