NGC-11 (10-17-11) Live Entertainment Tax Report This report, together with your remittance payable to the order of the NEVADA GAMING COMMISSION, is required to be filed MONTHLY, NOT LATER THAN THE 24th DAY OF THE MONTH, covering the preceding calendar month. For Operations During the Month of: Filing Deadline: Account No., Name, Address, Zip Code For Office Use Only Check Number Batch Number Entry Date Account No.: Legal Name: Trade Name: Address: City, State, Zip: Please correct if in error Please correct if in error THIS REPORT IS REQUIRED FOR THOSE LOCATIONS THAT LICENSE MORE THAN 50 SLOT MACHINES, MORE THAN 5 GAMES OR ANY COMBINATION THEREOF AND OFFER LIVE ENTERTAINMENT IN A FACILITY WITH A MAXIMUM OCCUPANCY OF LESS THAN 7500. FOR ALL OTHER LOCATIONS, THIS REPORT SHOULD ONLY BE COMPLETED IF ENTERTAINMENT IS PROVIDED IN A FACILITY WITH A MAXIMUM OCCUPANCY OF AT LEAST 200 AND AN ADMISSION CHARGE IS COLLECTED. Line 1. TAXABLE SALES NOTE: TAXABLE SALES FOR PURPOSE OF LET ARE NET OF SALES AND USE TAXES Line 2. LIVE ENTERTAINMENT TAX COMPUTATION [Amount on Line 1 times 10%] Line 3. PENALTY FOR LATE PAYMENT: NRS 463.270(5) $ Enter number of days late: A. Less than 10 days late: 25% of the amount due on Line 2, but not less than $50.00 and not more than $1000.00. B. Ten or more days late: 25% of the amount due on Line 2, but not less than $50.00 and not more than $5000.00 PENALTY DUE [Line 3A or Line 3B] Line 4. TOTAL AMOUNT DUE: [Line 2 + Line 3] $ Line 5. TOTAL REMITTANCE $ Check Number: Please return remittance payable to: NEVADA GAMING COMMISSION Return to the State Gaming Control Board, PO Box 8004, Carson City, NV 89702-8004. Pursuant to NRS 353.1467, payments made to the State, in the aggregate, that amount to $10,000.00 or more must be sent electronically. I, certify and declare under the penalties of perjury that I am the of the business named above; that this is a true, correct and complete report (Owner, Partner, President, Treasurer, Other-describe) to the best of my knowledge, information, and belief; and that this application and report is made with the knowledge and consent of all other individuals licensed. Dated Signed Person to contact regarding this report: Name: Phone: RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS American LegalNet, Inc. www.FormsWorkFlow.com