Revised 10/07/2020
Send all documentation to:
nvholder@nevadatreasurer.gov
Insurance Report Annual Report (all other business entities) Third-Party Audit
Name of person requesting exception:
Email: Must be email of person requesting exception or form will be rejected
Holder Name as it appears on online report (if multiple reports see
below):
Preferred Payment Method (check only one):
CHECK ACH CREDIT WIRE
Is your business capable of remitting payment via ACH Debit using our online portal? YES NO
If “NO”, provide detailed explanation below as to why not.
If “Yes”, please provide detailed explanation below. If additional space is required, please indicate below (“see attached”) and attach additional
documentation. If your company policies prevent ACH Debit, please state that below.
A holder that fails to make a payment as required by subsections 11 and 12 of NRS 120A.560 must be assessed by the administrator a fee for each
such payment in an amount equal to the greater of $50 or 2 percent of the amount of the payment. NRS 120A.730 for details.
If your request is approved, the FEIN/TIN on the holder report must also be provided in your EFT payment instructions when paying by ACH credit or
wire transfer. If paying by check, the FEIN must be disclosed on the check. If the request is incomplete, it will be rejected.
Must complete table below (see second page) for every report that this payment related to. This is a single use
exception. A request must be made annually if payment cannot be made by ACH debit.
This form must be submitted/approved prior to remitting payment. The deadline to submit is the 26
th
day of the month before the
report due date: Prior May 1st for insurance entities and prior to November 1st for non-insurance entities.
Please provide a detailed explanation and how your payment will be sent.
I declare to the best of my knowledge and belief that the information provided in this document and in any attached documentation is true and
correct and that the individual signing this form is an authorized officer of the entity.
Printed Name
Title of Authorized Officer
NEVADA STATE TREASURER – UNCLAIMED PROPERTY
ACH Debit Payment Exception Request Form
